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Background: We evaluated the effect of persistent hyperglycemia on outcomes in 1000 patients with intracerebral hemorrhage enrolled within 4.5 hours of symptom onset. Methods: We defined moderate and severe hyperglycemia based on serum glucose levels ≥140 mg/dL— Results: In the multivariate analysis, both moderate (odds ratio, 1.8 [95% CI, 1.1–2.8]) and severe (odds ratio, 1.8 [95% CI, 1.2–2.7]) hyperglycemia were associated with higher 90-day death or disability after adjusting for Glasgow Coma Scale score, hematoma volume, presence or absence of intraventricular hemorrhage, hyperlipidemia, cigarette smoking, and hypertension (no interaction between hyperglycemia and preexisting diabetes, P =0.996). Among the patients without preexisting diabetes, both moderate (odds ratio, 1.8 [95% CI, 1.0–3.2]) and severe (odds ratio, 2.0 [95% CI, 1.1–3.7]) hyperglycemia were associated with 90-day death or disability after adjusting for above mentioned potential confounders. Among the patients with preexisting diabetes, moderate and severe hyperglycemia were not associated with 90-day death or disability. Conclusions: Persistent hyperglycemia, either moderate or severe, increased the risk of death or disability in nondiabetic patients with intracerebral hemorrhage. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01176565.

Background: The appropriate timing of gastrostomy in patients with intracerebral hemorrhage who have dysphagia remains unclear. Objective: To identify factors and outcomes associated with timing of gastrostomy in patients with after hospitalization in the United States. Methods: We analyzed the data from the Nationwide Inpatient Sample (2016-2019), the largest all payer nationally representative dataset. We identified all patients presenting with primary diagnosis of intracerebral hemorrhage who underwent gastrostomy. Early gastrostomy was identified if gastrostomy was performed within 7 days of admission. We performed logistic regression analysis to identify the effect of timing of gastrostomy (early versus late) on none to minimal disability, length of stay, and hospitalization cost after adjusting for variables that were significantly different in univariate analysis. Results: Of 22,530 patients with intracerebral hemorrhage who underwent gastrostomy during hospitalization, 5765 (25.6%) underwent early gastrostomy. Patients who underwent early gastrostomy were more likely to be older (P Conclusion: Patients with intracerebral hemorrhage who undergo early gastrostomy are more likely to be discharged with none to minimal disability. Furthermore, early gastrostomy is associated with both reduction in hospital cost and length of stay.

Purpose: Hematoma expansion (HE) is associated with early clinical deterioration, worse long-term outcome, and higher mortality in ICH. Identification of patients at risk of HE may allow targeted anti-expansion therapies in future trials. We aimed to train and validate a deep learning model for prediction of HE based on admission non-contrast head CT. Methods: We utilized the clinical and imaging information from the Antihypertensive Treatment of Acute Cerebral Hemorrhage II (ATACH-2) trial and Yale ICH registry. All patients with spontaneous supratentorial ICH who had baseline head CT (28 were included. The HE was defined as an increase volume >33% or 6 ml. We trained a DenseNet121-based 3D convolutional neural network for prediction of HE (pipeline summarized in the Figure). Results: A total of 749 patients (610 from ATACH-2 and 183 from Yale) were randomly split (4:1) into 634 training/cross-validation (368 (58%) male, mean age of 62.8±13.1 years, median NIHSS 10, and 144 (23%) with HE); and 159 independent test set (92 (58%) male, mean age of 62.5±14.6 years, median NIHSS 12, and 36 (23%) with HE). The average of validation AUC in five-fold training/cross-validation was 0.62, with the best performing model achieving an AUC of 0.71 in validation fold. We then tested this model in the independent validation cohort isolated from training process, achieving an AUC of 0.67 in predicting HE. The attention heatmaps (Figure) confirm that deep learning model predictions were based on head CT regions containing ICH and perilesional edema. Conclusion: We could train, and independently validate a deep learning model for identification of supratentorial ICH patients at risk of impending HE. Compared to visual markers (including CTA spot sign), such model can provide an automated objective tool for future trial enrollment based on readily available non-contrast CT

Background and Purpose: Although many stroke centers in United States are using intravenous (IV) tenecteplase (TNK) for acute ischemic stroke patients, there is paucity of comparative data between IV TNK and IV alteplase from real-world settings. Materials and Methods: We analyzed the data from 122 healthcare facilities to determine the effect of IV TNK (compared with IV alteplase) on occurrence of two outcomes in acute ischemic stroke patients stratified by use of thrombectomy: non-routine discharge or death, and intracranial hemorrhage after adjusting for potential confounders. Results: Among 30,643 acute ischemic stroke patients analyzed, 29,480 (96.2%) and 1,163 (3.8%) patients received IV alteplase and IV TNK, respectively. The proportion of patients who received thrombectomy was significantly higher among patients who received IV TNK compared with those who received IV alteplase (16.7% versus 11.0%, p Conclusions: In an analysis of real-world data, IV TNK was associated with higher rates of intracranial hemorrhage compared with IV alteplase in patients with acute ischemic stroke.

Background: We quantified the effect of nationwide contrast media shortage, initiated on April 19 th , 2002 after GE Healthcare rationing, on evaluation of acute ischemic stroke (AIS) patients. Methods: We analyzed the data on 41,926 AIS patients (46,157 studies) who underwent imaging processed with Viz.ai software at 185 hospitals in the United States from Feb 28, 2022 through July 11, 2022. We quantified the overall (and in various strata) percentage change in daily number of computed tomographic angiography (CTA) and perfusions (CTP) performed, and the change in proportion of patients with large arterial occlusion (LVO) identified and image quality (CTP quality warnings) before and after April 19 th . Results: The daily counts of unique patients who underwent CTA decreased (a 14% reduction) in April: from 2.099 studies (before April 19 th ) to 1.811 studies (after April 19 th ) per day per hospital (see Figure). The reduction was most prominent in comprehensive stroke centers and in sites that used GE contrast media (24% versus 12%). There was no change in the proportions of patients with LVO identified (8.69% versus 9.34%) and inadequate tests (5.86% versus 5.00%). Conclusions: There was a prominent reduction in CTA performed in the United States due to contrast media shortage. However, the proportion of patients with LVO identified was not affected.

Introduction: Although there is emphasis on performing carotid artery stent placement (CAS) within two weeks after index event of transient ischemic attack (TIA) or minor stroke in patients with cervical internal carotid artery (ICA) stenosis, the risk and characteristics of recurrent cerebral ischemic events while waiting for CAS are not well defined. Method: We analyzed patients admitted to our institution over a 45-month period with symptomatic cervical ICA stenosis. All patients were initiated on daily aspirin and clopidogrel 75mg on the day of admission. We identified any new cerebral ischemic events that occurred between index event and CAS and categorized them as TIA, and minor or major ischemic strokes. We calculated the risk of new ipsilateral cerebral ischemic events between index ischemic event and CAS. Results: The mean age of 150 patients analyzed was 67 years (range: 46-94 years; 106 were men); and 94 and 56 patients had ≥ 70% and 50-69% stenosis, respectively. The mean and median time intervals between index event and CAS performance were 25 and 6 days, respectively. A total of 6 new cerebral ischemic events (5 TIAs and 1 major stroke) were observed over 3,776 patient days of observation. The risk of new ipsilateral cerebral ischemic events between index ischemic event and CAS performance was 1.6 per 1000 patient days of observation. Conclucion: We identified a low risk of new ipsilateral cerebral ischemic events in patients with ≥ 50% ICA stenosis while waiting for CAS presumably due to early initiation of dual antiplatelets.

Background and Purpose: Acute ischemic stroke may occur in patients with coronavirus disease 2019 (COVID-19), but risk factors, in-hospital events, and outcomes are not well studied in large cohorts. We identified risk factors, comorbidities, and outcomes in patients with COVID-19 with or without acute ischemic stroke and compared with patients without COVID-19 and acute ischemic stroke. Methods: We analyzed the data from 54 health care facilities using the Cerner deidentified COVID-19 dataset. The dataset included patients with an emergency department or inpatient encounter with discharge diagnoses codes that could be associated to suspicion of or exposure to COVID-19 or confirmed COVID-19. Results: A total of 103 (1.3%) patients developed acute ischemic stroke among 8163 patients with COVID-19. Among all patients with COVID-19, the proportion of patients with hypertension, diabetes, hyperlipidemia, atrial fibrillation, and congestive heart failure was significantly higher among those with acute ischemic stroke. Acute ischemic stroke was associated with discharge to destination other than home or death (relative risk, 2.1 [95% CI, 1.6–2.4]; P P =0.03) after adjusting for potential confounders. Conclusions: Acute ischemic stroke was infrequent in patients with COVID-19 and usually occurs in the presence of other cardiovascular risk factors. The risk of discharge to destination other than home or death increased 2-fold with occurrence of acute ischemic stroke in patients with COVID-19.

Background: To highlight the heterogeneity of acute temporal blood pressure (BP) changes in the ATACH-2 trial (Antihypertensive Treatment of Acute Cerebral Hemorrhage-2) and associations with the outcomes of intracerebral hemorrhage. Methods: One thousand patients with acute intracerebral hemorrhage, who had been randomized to intensive (110–139 mm Hg) or standard (140–179 mm Hg) systolic BP (SBP) lowering with intravenous nicardipine in ATACH-2 from 2011 to 2015, were analyzed about temporal changes in hourly maximum SBP up to 24 hours after randomization using group-based trajectory modeling. Outcomes included death or disability (modified Rankin Scale score 4–6) at 3 months, neurological deterioration within 24 hours (≥2-point decrease in Glasgow Coma Scale score or ≥4-point increase in National Institutes of Health Stroke Scale score), and acute kidney injury (≥0.3 mg/dL within 48 hours or ≥1.5-fold increase in serum creatinine) within 7 days after onset. Results: Group-based trajectory modeling revealed 4 SBP trajectory groups: moderate SBP (from ≈190 mm Hg at hospital arrival to 150–160 mm Hg after randomization; n=298), moderate-to-low SBP (from ≈190 mm Hg to 210 mm Hg to 210 mm Hg to 160–170 mm Hg; n=173). Patients with intensive treatment accounted for 11.1%, 88.6%, 85.1%, and 1.7% of each group, respectively. Compared with the moderate-to-low SBP group, the high-to-low SBP group showed increased risks of death or disability at 3 months (adjusted odds ratio, 2.29 [95% CI, 1.24–4.26]) and acute kidney injury (adjusted odds ratio, 3.50 [95% CI, 1.83–6.69]), while no increase in neurological deterioration was seen in this group (adjusted odds ratio, 0.48 [95% CI, 0.20–1.13]). The moderate SBP and high SBP groups showed no significant risk differences for such outcomes. Conclusions: Data-driven observation using a group-based trajectory modeling approach may be useful to clarify the relationship between antihypertensive treatment, temporal SBP changes, and outcomes in acute intracerebral hemorrhage. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01176565.

Background and Purpose: Evidence regarding sex differences in clinical outcomes and treatment effect following intracerebral hemorrhage is limited. Using the ATACH-2 trial (Antihypertensive Treatment in Intracerebral Hemorrhage-2) data, we explored whether sex disparities exist in outcomes and response to intensive blood pressure (BP)–lowering therapy. Methods: Eligible intracerebral hemorrhage subjects were randomly assigned to intensive (target systolic BP, 110–139 mm Hg) or standard (140–179 mm Hg) BP-lowering therapy within 4.5 hours after onset. Relative risk of death or disability corresponding to the modified Rankin Scale score of 4 to 6 was calculated, and interaction between sex and treatment was explored. Results: In total, 380 women and 620 men were included. Women were older, more prescribed antihypertensive drugs before onset, and had more lobar intracerebral hemorrhage than men. Hematoma expansion was observed less in women. After multivariable adjustment, the relative risk of death or disability in women was 1.19 (95% CI, 1.02–1.37, P =0.023). The relative risk of death or disability between intensive versus standard BP-lowering therapy was 0.91 (95% CI, 0.74–1.13) in women versus 1.13 (95% CI, 0.92–1.39) in men ( P for interaction=0.11), with inconclusive Gail-Simmon test ( P =0.16). Conclusions: Women had a higher risk of death or disability following intracerebral hemorrhage. The benefit of intensive BP-lowering therapy in women is inconclusive, consistent with the overall results of ATACH-2. Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT01176565.

Objectives: Acute ischemic stroke patients with severe acute respiratory syndrome coronavirus maybe candidates for acute revascularization treatments (intravenous thrombolysis and/or mechanical thrombectomy). Materials and Methods: We analyzed the data from 62 healthcare facilities to determine the odds of receiving acute revascularization treatments in severe acute respiratory syndrome coronavirus infected patients and odds of composite of death and non-routine discharge with severe acute respiratory syndrome coronavirus infected and non-infected patients undergoing acute revascularization treatments after adjusting for potential confounders. Results: Acute ischemic stroke patients with severe acute respiratory syndrome coronavirus infection were significantly less likely to receive acute revascularization treatments (odds ratio 0.6, 95% confidence interval 0.5-0.8, p=0.0001). Among ischemic stroke patients who received acute revascularization treatments, severe acute respiratory syndrome coronavirus infection was associated with increased odds of death or non-routine discharge (odds ratio 3.0, 95% confidence interval 1.8-5.1). The higher odds death or non-routine discharge (odds ratio 2.1, 95% confidence interval 1.9-2.3) with severe acute respiratory syndrome coronavirus infection were observed in all ischemic stroke patients without any modifying effect of acute revascularization treatments (interaction term for death (p=0.9) or death or non-routine discharge (p=0.2). Conclusions: Patients with acute ischemic stroke patients with severe acute respiratory syndrome coronavirus infection were significantly less likely to receive acute revascularization treatments. Severe acute respiratory syndrome coronavirus infection was associated with a significantly higher rate of death or non-routine discharge among acute ischemic stroke patients receiving revascularization treatments.

Objective: To investigate the effect of early hyperchloremia on 90-day outcomes in acute ischemic stroke Methods: We analyzed data from Albumin in Acute Ischemic Stroke (ALIAS) Part 1 and 2 trials which recruited patients with acute ischemic stroke within 5 hours of onset. Patients with hyperchloremia (defined as 110 mmol/L or greater) at baseline, 24, or 48 hours after randomization were identified. We trichotomized patients into 3 groups; no instances, one instance, and two or more instances of measured hyperchloremia within the first 48 hours. Serum creatinine levels at baseline, 24, and 48 hours were used to identify acute kidney injury (AKI) via the Acute Kidney Injury Network (AKIN) classification. Logistic regressions were performed to determine the effects of hyperchloremia on outcomes defined by modified Rankin scales or National Institutes of Health Stroke Scale scores at 90 days and mortality at 90 days. Results: Among the total of 1275 patients analyzed, zero, one and two or more occurrence of hyperchloremia within 48 hours were observed in 976, 191 and 108 patients respectively. Compared with patients without hyperchloremia, patients with two or more occurrences of hyperchloremia at significantly higher odds of non-favorable outcomes within 90 days after adjustment for age, NIHSS score, initial systolic blood pressure, and ALIAS treatment group (albumin or placebo) (OR 3.0, 95%, CI 1.8-5.0). Patients with two or more occurrences of hyperchloremia also presented higher odds of death within 90 days vs the non-hyperchloremia group. Patients with one occurrence of hyperchloremia were not at higher odds for non-favorable outcomes at 90 days. There was no association between occurrence of two or more occurrence of hyperchloremia and AKI (OR 0.8, 95% CI 0.3-1.9). Conclusions: The independent association between sustained hyperchloremia and non-favorable outcomes at 90 days suggest that avoidance of hyperchloremia may increase the rate of favorable outcomes in patients with acute ischemic stroke.

Background and Purpose: Intracerebral hemorrhage can occur in acute ischemic stroke patients receiving alteplase (recombinant tissue plasminogen activator). Antifibrinolytic medications such as the synthetic lysine analogs tranexamic acid and ε;-aminocaproic acid that inhibit fibrinolysis by attaching to the lysine-binding site of the plasminogen molecule have been utilized. However, the efficacy of antifibrinolytic medication in prevention of hematoma expansion is not known. Methods: We analyzed the effect of antifibrinolytic medication in acute ischemic stroke patients with intracerebral hemorrhage associated with Alteplase from 2012 to 2017. The Region-of-Interest method on a Horos Open Source Medical Image Viewer (Version 3.3.6) was utilized for volume measurement. We compared the change in hemorrhage volume in patients who did and did not receive antifibrinolytic medication. Results: A total of 36 patients (mean age 72.7±11.5, 56% were men) who received intravenous alteplase with subsequent intracerebral hemorrhage were identified. Fourteen patients received antifibrinolytic treatment; five patients had reduction or stabilization in hematoma volume (overall pre-treatment volume 13.87±15.74 cm 3 and post-treatment volume 16.74±29.67 cm 3 ). Mean fibrinogen level in the antifibrinolytic medication group was 297 mg/dL; two patients had levels < 200 mg/dL. In the cohort of patients did not receive antifibrinolytics, 15 out of 22 patients had reduction or stabilization in hematoma volume (overall pre-treatment volume 19.25±33.33 cm 3 and post-treatment volume 17.41±26.56 cm 3 ). Mean volume difference in the group that received antifibrinolytic medication was 36% and 9% in the group that did not receive antifibrinolytic medication. [Figure 1] Conclusion: We did not identify any advantage of antifibrinolytic treatment in reduction or stabilization in hematoma volume in patients with Alteplase-associated intracerebral hemorrhages.

Introduction: Hematoma expansion (HE) in patients with intracerebral hemorrhage (ICH) is a key predictor of poor prognosis and potentially amenable to treatment. Current clinical scoring models, radiological markers, and labs have limited ability to predict HE. This study aimed to create a more robust classification model to predict HE in patients with ICH using a deep learning algorithm, an artificial neural network (ANN). Methods: Data from the ATACH 2 trial (Antihypertensive Treatment of Acute Cerebral Hemorrhage) was utilized. Variables included in the models were chosen as per literature consensus on salient factors associated with HE and clinical expertise. HE was defined as increase in either >33% or 6mL in hematoma volume in the first 24 hours. A multi-layer feedforward ANN was trained using the back-propagation method to minimize the loss function with 5-fold cross validation. 80% of patients were used for training and 20% for testing. The ANN was compared to a logistic regression model (GLM). Given the imbalance in patients with HE, AUPRC (area under the precision-recall curve), recall and precision were calculated for the respective models. Results: Of the 963 patients in the study (mean age 62±13.0, 38.5% female), 31% had hematoma expansion. The median [interquartile range (IQR)] initial hematoma volume was 10.5mm 3 [5.16 - 20.25], median admission SBP [IQR] was 200 [184-217], median platelet count [IQR] was 213 [178-256], median INR [IQR] was 1.0 [0.9-1.0], and median admission GCS [IQR] was 15 [13-15]. The GLM model had AUPRC of 0.38 with recall of 0.60 and precision of 0.38 in the testing cohort. The ANN training model demonstrated AUPRC of 0.92 with recall of 0.72 with precision of 0.39 during testing. Initial ICH volume, platelets, INR, and GCS had the highest feature importance. Conclusion: We developed an ANN to predict HE in ICH patients performing with improved sensitivity and similar positive predictive value when compared to GLM. We support that ANN can capture complex associations between variables not attainable in classic regression models. This model may help identify patients at risk for HE who warrant careful monitoring and aggressive treatment upfront including those suitable for clinical trials for treatments.

Background: Clopidogrel bolus is an option used prior to carotid artery stent placement (CAS) when sustained clopidogrel pre-treatment is not used. Objective: To compare the effect of clopidogrel bolus (450 mg administered ≥4 hours) with sustained clopidogrel pre-treatment (48 hours or greater) prior to CAS in patients prospectively followed over 10 years in Carotid Revascularization Endarterectomy versus Stenting Trial (CREST). Methods: The rates of primary endpoint (composite of any stroke, myocardial infarction (MI), or death during the periprocedural period or ipsilateral stroke within 4 years after randomization) were compared between patients who received clopidogrel bolus with those who received sustained clopidogrel pre-treatment after adjusting for age, gender, symptomatic status and initial severity of stenosis (≥70% versus Results: The rate of periprocedural stroke (7.3% versus 3.4%, p=0.03) and primary end point (11.3% versus 5.9%, p=0.02) was significantly higher among patients who received clopidogrel bolus. The risk of primary end point was significantly higher in patients who received clopidogrel bolus (hazards ratio [HR] 1.9, 95% confidence interval [CI] 1.1-3.4, p=0.02) after adjusting for potential confounders. The overall mean (± SD) primary end point free survival based on Kaplan-Meier analysis was 7.0±0.2 years for patients who received clopidogrel bolus and 8.9±0.1 years for those who received sustained clopidogrel pre-treatment (log-rank test P=0.011). Conclusion: Clopidogrel bolus was associated with higher rates of adverse outcomes compared with sustained clopidogrel pre-treatment in patients who underwent CAS. Therefore, clopidogrel bolus may not be equivalent to sustained clopidogrel pre-treatment.

Context: Transradial access has been increasingly utilized for neurointerventional procedures including carotid angioplasty and stent placement (CAS) over the past decade. At our center, we adopted transradial approach as the preferred approach in 2020. Objective: To compare the results of transradial approach with transfemoral approach for CAS as part of a quality assurance initiative. Methods: We analyzed data collected for all non-urgent CAS procedures performed at our institute in the last 24 months by same interventionalists to minimize inter-operator variability. We looked at the rates of technical failure; hemorrhagic complications classified as major (hemoglobin decrease >5 g/dL or intracranial hemorrhage with deficits), minor (hemoglobin decreases 3-5 g/dL or intracranial hemorrhage without residual deficits), or insignificant; and any stroke and/or death within 1-month post procedure. Results: A total of 182 non-urgent CAS procedures were performed at our institution; 116 (64%) were initiated using transfemoral approach and 66 (36%) were initiated using transradial approach. The median age was similar between the two group (66.5 years versus 66.7 years). There were 6 (3%) CAS procedures initiated using transradial approach but later converted to transfemoral due to anatomical and/or technical difficulties. One (0.6%) CAS procedure initiated using transfemoral approach was converted to transradial approach due to severe iliofemoral atherosclerosis. The rates of any stroke and/or death were 1.6% (n=1) and 3.3%% (n-=4) in patients undergoing CAS using transradial and transfemoral approaches, respectively. The rate of major hemorrhagic complications were 1.6% (n=1) and 5.7% (n-=7) in patients undergoing CAS using transradial and transfemoral approaches, respectively. Conclusions: The rates of major hemorrhagic complications were lower among patients who underwent CAS via transradial approach compared with CAS using transfemoral approach although the rates of technical failure remain relatively high with transradial approach.

Background: Undiagnosed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection may be seen in acute stroke patients. Rapid screening is important to reduce exposure to medical professionals and other patients during acute assessment and treatment. Chest computed tomographic (CT) scan may be another time-sensitive option for identification of SARS-CoV-2 infection in acute stroke patients. Objective: We report our experience of incorporating chest CT scan in the initial neuroimaging protocol for evaluation of acute stroke patients. Methods: All acute stroke patients underwent chest CT scan concurrent to CT head, CT angiogram of head and neck and CT perfusion for 10 months. We identified patients who had chest CT scan findings that were suggestive of SARS-CoV-2 infection including bilateral, multilobar ground glass opacification with a peripheral or posterior distribution, and/or consolidation. All patients subsequently underwent polymerase chain reaction (PCR) testing using nasopharyngeal specimen for identification of SARS-CoV-2 with contact isolation. Sensitivity, specificity, and likelihood ratios were calculated. Results: A total of 530 consecutive acute stroke patients (mean age in years 65.6± SD; 15.4; 280 were men) underwent neuroimaging with concurrent chest CT scan. The chest CT scan identified findings suggestive of SARS-CoV-2 infection in 34 (6.4%) patients. Subsequent PCR testing confirmed the diagnosis of SARS-CoV-2 infection in 21 of 34 patients. Among 491 patients in whom chest CT scan did not identify any findings suggestive of SARS-CoV-2 infection, 387 underwent PCR tests; PCR testing confirmed the diagnosis of SARS-CoV-2 infection in 13 of 34 patients. Sensitivity and specificity of chest CT scan for detecting SARS-CoV-2 infection was 61.9% and 96.2%, respectively. Positive and negative likelihood ratio of chest CT scan for detecting SARS-CoV-2 infection is 16.26 and 0.39, respectively. Conclusions: Although specificity was high, the relatively low sensitivity of chest CT scan in identifying SARS-CoV-2 infection limits the value of adding this imaging to standard neuroimaging in acute stroke patients. At our institution, we have subsequently discontinued the protocol.

Background and Purpose: Persistent dysphagia requiring gastrostomy tube placement continues to be a major issue for stroke patients. We performed analysis to evaluate trends in utilization of gastrostomy tube placement and associated rates of death among acute ischemic stroke (IS) and intracerebral hemorrhage (ICH) patients over a 10-year period. Methods: We obtained data for patients admitted to hospitals in United States from 2009 to 2018 with a primary diagnosis of IS or ICH using a large national database. We determined rate and pattern of utilization and associated in-hospital outcomes of gastrostomy tube placement among IS and ICH patients. Results: A total of 50551 (7.05%) and 136922 (2.45%) patients underwent gastrostomy tube placement among the 716777and 5567538patients admitted with ICH and IS, respectively. There was a 3.2-fold decrease in patients who gastrostomy tube placement among patients with IS (2.3% in 2009 vs 0.7% in 2018; P Conclusions: Between 2009 and 2018, there has been a significant reduction in the proportion of IS and ICH patients who underwent gastrostomy tube placement. However, the length and cost of hospitalization remained significantly higher among patients who underwent gastrostomy tube placement.

Context: Current guidelines recommend bed rest for 24 hours after receiving intravenous alteplase which may not be necessary and delay rehabilitation in a large proportion of acute ischemic stroke patients. Objective: To determine the feasibility of “early mobilization protocol” within the intensive care unit (ICU) in patients with acute ischemic stroke who received intravenous alteplase. Methods: All consecutive patients were admitted to the ICU with an acute ischemic stroke who received intravenous alteplase from October 2019-June 2021 were considered for “early mobilization protocol”. Patients≥18 years of age with minor, moderate or severe ischemic stroke (NIHSS score ≤22) were eligible and mobilization was initiated within 13-24 hours after intravenous alteplase administration. Exclusion criteria included hemodynamic instability, on mechanical ventilation, unstable neurological examination or progressive symptoms, or presence of external ventricular drain for hemorrhagic transformation within 24 hours of intravenous alteplase. Results: A total of 137 patients (56.8%) patients were eligible among 241 patients who were admitted to our institution with acute ischemic stroke after receiving intravenous alteplase. Mean age (±SD) was 63.4±16.6 and 66.2±17.0 years for the patients included and excluded in the early mobilization protocol, respectively. The mean NIHSS score (±SD) at baseline was 5.3±4.4 and 9.9±7.3 for the patients included and excluded in the early mobilization protocol, respectively. Early mobilization protocol was initiated at 18.3±3.6 hours in eligible patients compared with routine mobilization initiated at 41.6±19.8 hours in excluded patients (p Conclusion: Early mobilization protocol in patients post intravenous alteplase treatment can be initiated in the ICU in appropriately selected patients without any adverse effects on neurological and functional outcomes.

Background and Purpose: Hyperglycemia has been associated with higher rates of death or disability in acute ischemic stroke patients undergoing endovascular treatment. However, it remains unclear whether intensive serum glucose reduction can reduce the rates of death or disability in patients undergoing endovascular treatment. Methods: We analyzed the effect of intensive (serum glucose Results: A total of 146 patients (mean age 68.1±13.9, 50.7% were men) underwent endovascular treatment for acute ischemic stroke; 72 and 74 patients were randomized to intensive and standard treatments, respectively. The rates of death (20.3%, and 22.2%), favorable 90-day primary outcome (17.6% and 19.4%), and serious adverse events (41.9% and 56.98%) were similar between the two groups. The area under the curve of serum glucose was not associated with death within 90 days (OR 1, 95% CI 1-1) or favorable outcome at 90 days (OR 1, 95% CI 1-1). Glucose variability was not associated with death or favorable outcome at 90 days. Intensive treatment was not associated with cerebral hemorrhagic events. Conclusion: We did not identify any beneficial effect of intensive glucose reduction on rates of death or favorable outcomes at 90 days among acute ischemic stroke patients undergoing endovascular treatment. We also did not observe any relationship between various glycemic parameters and death or favorable outcomes at 90 days.

Supplemental Digital Content is available in the text., Background and Purpose: The frequency of ischemic stroke in patients with coronavirus disease 2019 (COVID-19) varies in the current literature, and risk factors are unknown. We assessed the incidence, risk factors, and outcomes of acute ischemic stroke in hospitalized patients with COVID-19. Methods: We included patients with a laboratory-confirmed SARS-CoV-2 (severe acute respiratory syndrome coronavirus-2) infection admitted in 16 Dutch hospitals participating in the international CAPACITY-COVID registry between March 1 and August 1, 2020. Patients were screened for the occurrence of acute ischemic stroke. We calculated the cumulative incidence of ischemic stroke and compared risk factors, cardiovascular complications, and in-hospital mortality in patients with and without ischemic stroke. Results: We included 2147 patients with COVID-19, of whom 586 (27.3%) needed treatment at an intensive care unit. Thirty-eight patients (1.8%) had an ischemic stroke. Patients with stroke were older but did not differ in sex or cardiovascular risk factors. Median time between the onset of COVID-19 symptoms and diagnosis of stroke was 2 weeks. The incidence of ischemic stroke was higher among patients who were treated at an intensive care unit (16/586; 2.7% versus nonintensive care unit, 22/1561; 1.4%; P=0.039). Pulmonary embolism was more common in patients with (8/38; 21.1%) than in those without stroke (160/2109; 7.6%; adjusted risk ratio, 2.08 [95% CI, 1.52–2.84]). Twenty-seven patients with ischemic stroke (71.1%) died during admission or were functionally dependent at discharge. Patients with ischemic stroke were at a higher risk of in-hospital mortality (adjusted risk ratio, 1.56 [95% CI, 1.13–2.15]) than patients without stroke. Conclusions: In this multicenter cohort study, the cumulative incidence of acute ischemic stroke in hospitalized patients with COVID-19 was ≈2%, with a higher risk in patients treated at an intensive care unit. The majority of stroke patients had a poor outcome. The association between ischemic stroke and pulmonary embolism warrants further investigation.

Background and Purpose: Acute ischemic stroke may occur in patients with Coronavirus disease 2019 but risk factors, in hospital events, and outcomes are not well studied in large cohorts. We identified risk factors, co-morbidities, and outcomes in patients with Coronavirus disease 2019 with or without acute ischemic stroke and compared with patients without Coronavirus disease 2019 and acute ischemic stroke. Methods: We analyzed the data from 54 healthcare facilities using the Cerner de-identified Coronavirus disease 2019 dataset. The dataset included patients with an emergency department or inpatient encounter with a discharge diagnoses codes that could be associated to suspicion of or exposure to Coronavirus disease 2019, or confirmed Coronavirus disease 2019. Results: A total of 103 (1.3%) patients developed acute ischemic stroke among 8,163 patients with Coronavirus disease 2019. Among all Coronavirus disease 2019 patients, the proportion of patients with hypertension, diabetes mellitus, hyperlipidemia, atrial fibrillation and congestive heart failure was significantly higher among those with acute ischemic stroke. Acute ischemic stroke was associated with discharge to destination other than home or death (relative risk 2.1, 95% confidence interval 1.7-2.4, p Conclusions: Acute ischemic stroke was infrequent in patients with Coronavirus disease 2019 and usually occurs in presence of other cardiovascular risk factors. The risk of discharge to destination other than home or death increased two folds with occurrence of acute ischemic stroke in patients with Coronavirus disease 2019.

Background and purpose: To determine if computed tomography (CT) perfusion (CTP) abnormalities in patients with transient ischemic attacks (TIA) are associated with development of ischemic strokes or adverse cardiovascular events within 24 months. Methods: Patients with a diagnosis of TIA who underwent CTP within 24 hours of symptom onset as part of the stroke/TIA imaging protocol were analysed. Abnormality was defined as an area of well demarcated mean transit time delay and/or cerebral blood flow reduction corresponding to an arterial territory as identified by an independent neuroradiologist. The patients were followed for at least 3 months and up to 24 months to identify occurrence of ischemic stroke and cardiovascular events (myocardial infarction or ischemia). Results: A total of 78 patients (mean age 67.60 +/- 15.1 ; 48 were men) with a diagnosis of TIA. A total of 17 patients (22%) had documented CTP abnormalities. Patients with CTP abnormalities were older and more likely to be men. There was no difference in the rates of ischemic stroke (5.9 % vs 3.3 %), or cardiovascular events (0% versus 1.6 %) when patients with CTP abnormalities were compared to those with normal CTP. Conclusions: In patients with TIA, an abnormal CTP does not predict the occurence of new ischemic stroke or cardiovascular events during follow up.

Background: Histamine (H) 2 blockers led to a significant increase of the relative bioavailability of nimodipine and therefore may change tolerability of nimodipine in patients with aneurysmal subarachnoid hemorrhage (SAH). Objective: To determine the effect of H2 blockers on outcome of SAH patients being treated with nimodipine on outcomes. Methods: We analyzed data from Cerner Health Facts® which collected data from participating facilities from January 1st, 2000 to July 1st, 2018. We identified SAH patients who underwent endovascular or surgical treatment for intracranial aneurysm and received nimodipine with or without H2 blockers. Outcome was defined by discharge destination and classified into none to minimal disability, moderate to severe disability, or death. Results: A total of 815 (54.8%) of 1488 SAH patients received H2 blockers in addition to nimodipine. There were no differences in rates of cerebral ischemia (8.8% versus 9.8%) or performance of angioplasty (3.8% versus 3.7%) between patients who did or did not receive H2 blockers. There were no differences in rates of intubation/mechanical ventilation (26.0% versus 29.3%) or intra-procedural cerebral infarction (3.4% versus 2.8%) between the two groups. There was no difference in in hospital mortality rates (10.9% versus 10.2%) or none to minimal disability (41.8% versus 38.2%) between patients who did or did not receive H2 blockers. Conclusions: H2 blockers are frequently used with nimodipine in SAH patients and did not appear to adversely affect rates of death or disability. The finding does not support any clinically significant interaction between H2 blockers and nimodipine in SAH patients.

Background: To identify the beneficial effects of thrombectomy capable hospitals (TCHs), we compared the rates of in-hospital adverse events and discharge outcomes among ischemic stroke patients admitted to thrombectomy capable and non-thrombectomy capable hospitals in the United States. Methods: We obtained the data from the Nationwide Inpatient Sample from 2012 and 2017. Thrombectomy capable hospitals were identified based on number of thrombectomy procedures performed by hospital per year among ischemic stroke patients. If an hospital performed ten or more thrombectomy procedures, it was labelled as thrombecotomy capable hospital. The analysis was limited to patients (age ≥18 years) discharged with a principal diagnosis of ischemic stroke (International Classification of Disease 433.x1-434.x1 (ICD-9) or I63 (ICD-10). The impact of TCHs admissions on in-hospital outcomes was assessed in a comparative analysis of propensity-matched groups of patients. Results: We identified a total of 2,826,335 patients with primary ischemic stroke patients. After adjusting for age, gender, race or ethnicity, comorbidities, All Patients Refined Diagnosis Related Groups (APR-DRG)-based disease severity, and hospital teaching status, patients admitted to TCHs were at lower risk of in-hospital adverse events complications: pneumonia (odds ratio [OR], 0.86; 95% confidence interval [CI], 0.80-0.93), urinary tract infection (OR, 0.87; 95% CI, 0.84-0.91)and sepsis (OR, 0.92; 95% CI, 0.84-1.00). Patients admitted to TCH were more likely to receive thrombolysis (OR, 1.29; 95% CI, 1.30-1.36). The mean cost of hospitalization of the patients was significantly higher in patients admitted at TCHs compared with those admitted at non-thrombectomy capable $74765 vs $60530, P < .0001). The patients admitted to TCHs had lower inpatient mortality (OR, 0.82; 95% CI, 0.78-.88) and were more likely to be discharged with none to minimal disability (OR, 1.09; 95% CI, 1.06-1.12). Conclusions: Compared with non-thrombectomy capable admissions, patients admitted to TCHs are less likely to experience hospital adverse events and more likely to experience better discharge outcomes.

Background and Purpose: In present-day intracerebral hemorrhage (ICH) trials, hematoma expansion (HE) is often analyzed as a binary variable - present or absent. However, dichotomizing intrinsically wide-ranging variables discards substantial information reflective of treatment effect and can reduce the ability to detect relationships between the exposure and outcome of interest. We explored the concept of a “HE shift analysis” as a novel analytic mode for ICH treatment trials using previously published clinical trial data. Methods: Using data from the Antihypertensive Treatment of Acute Cerebral Hemorrhage II (ATACH-2) trial, patients were stratified by treatment status (intensive vs. standard blood pressure lowering with IV nicardipine) and HE shift was evaluated by generating strata based on a) previously established HE definitions, b) quartiles of 24-hour total hematoma volume, and c) quartiles of 24-hour total hematoma volume (THV) change. The relationship between blood pressure treatment and hematoma expansion shift was explored using proportional odds models and adjusted Wilcoxon testing. Results: The primary analysis population included 863 patients. In both treatment groups, approximately one-third of patients exhibited no hematoma growth. Using a conventional threshold, significant intraparenchymal expansion (≥33%) was reduced by 5.8% in those assigned to the intensive therapy arm (aOR: 0.77 [95% CI: 0.60-0.99], Figure 1A). The stratified quartiles of 24-hour total hematoma volumes were associated with a 5% shift within the highest and lowest strata in the intensive arm, (aOR: 0.83 [0.66-1.05], Figure 1B). Intensive therapy was associated with a 5.2% reduction from > 3 mL to 0.5-3 mL (aOR: 0.86 [0.68-1.09], Figure 1C). Conclusions: A shift analysis model of HE provides additional insights into the biological effects of a given therapy and may be an alternate way to assess hemostatic agents in future hemorrhage trials.

Context: Over the past few decades, transradial access has been increasingly utilized for neurointerventional procedures including carotid angioplasty and stent placement (CAS). Objective: To compare the outcomes of CAS performed via transradial approach with those performed using transfemoral approach within the same institution. Methods: We analyzed all the elective CAS procedures performed at our institute in the last 48 months and divided the procedures based on initial approach (transradial or transfemoral). Both approaches were used by same interventionalists to minimize inter-operator variability. We compared the rates of technical failure; hemorrhagic complications classified as major (hemoglobin decrease >5 g/dL or intracranial hemorrhage with deficits), minor (hemoglobin decreases 3-5 g/dL or intracranial hemorrhage without residual deficits), or insignificant; and any stroke and/or death within 1-month post procedure. Results: A total of 120 elective CAS procedures were performed at our institution; 84 patients (70%) were initiated as transfemoral and 36 patients (30%) were initiated as transradial approach. There were 6 (16%) CAS procedures initiated as trans-radial but later switched to transfemoral due to anatomical and/or technical difficulties. Similarly, 1(1.2%) procedure was switched to transradial from transfemoral. So finally, 89 (74%) patients had transfemoral approach and 31 (26%) patients had transradial approach to CAS. The median age was similar between the two groups (66.5 years versus 67.3 years).The rates of major hemorrhagic complications were 2 (2.2 %) and 0 (0%) in CAS performed using tranfemoral and tranradial approaches, respectively. The rate of any stroke and/or death within 30 days post procedure was 5 (5.6 %) and 1 (3.2 %) in CAS performed using transfemoral and transradial approaches, respectively.The median fluoroscopy time was 36.1 minutes and 34.4 minutes using transfemoral and transfemoral approaches, respectively (p =0.72). Conclusions: Transradial approach is comparable to transfemoral approach for performance of CAS in regard to clinical endpoints although the rates of technical failure remain relatively high in patients in whom CAS was initiated from transradial approach.

Background: Intra-arterial or intravenous platelet glycoprotein (GP) IIb/IIIa inhibitors have been used as adjunct to stent placement of carotid stenosis in patients with ischemic stroke or transient ischemic attack. Objective: To determine the proportion of patients with ischemic stroke or transient ischemic attack who received platelet GP IIb/IIIa inhibitors as adjunct to carotid stent placement and associated outcomes. Methods: We analyzed data from Cerner Health Facts® which collected data from participating facilities from January 1, 2000 to July 1, 2018. We identified patients with ischemic stroke or transient ischemic attack who underwent carotid stent placement for carotid stenosis and received Abciximab, Eptifibatide, or Tirofiban. Outcome was defined by discharge destination and classified into none to minimal disability, moderate to severe disability, or death. Results: A total of 8.4 % of 4567 patients with ischemic stroke or transient ischemic attack who underwent carotid stent placement for carotid stenosis received platelet GP IIb/IIIa inhibitors. Patients who received platelet GP IIb/IIIa inhibitors were more likely to experience cerebral ischemia (14.8% versus 7.5%) and undergo intubation/mechanical ventilation (4.4% versus 2%). There was a significant difference between patients who did or did not receive platelet GP IIb/IIIa inhibitors in terms of in hospital mortality rates (2.7% versus 1.2%, p=0.0152), none to mild disability (67.3% vs 75.7%, p=0.0003), and moderate to severe disability (30.1% vs 23.1%,p=0.0024). Conclusions: Adjunct use of platelet GP IIb/IIIa inhibitors in patients undergoing carotid stent placement for symptomatic carotid stenosis was associated with increased rates of in hospital mortality and moderate to severe disability.

Background: Recent trials have demonstrated a reduction in death or disability with endovascular treatment in patients with acute ischemic strokes. However, readmission rates and predictors are not known. Objective: To identify rates and factors associated with 30-day readmission after endovascular treatment in ischemic stroke patients. Methods: Nationwide Readmissions Data (NRD) between 2010 and 2017 was utilized to identify endovascular treatment in acute ischemic stroke patients using ICD-9 and ICD-10 codes. We used hierarchical logistic regression model to identify factors associated with 30-day readmissions. Results: Among 17, 562 acute ischemic stroke patients who survived to discharge after endovascular treatment, 2334 (13.29%) were readmitted within 30-days. Age => 65 years (odds ratio [OR]: 1.23, 95% confidence interval [CI]: 1.09 to 1.39, p =0.0005), chronic kidney disease (OR: 1.28, 95%CI: 1.12 to 1.47, p = 0.0004), congestive heart failure (OR: 1.25, 95%CI: 1.13 to 1.39, p Conclusion: In this large nationally representative study, nearly one in 10 patients were readmitted within 30 days after discharge in acute ischemic stroke patients undergoing endovascular treatment. Medical comorbidities and post procedure intracranial hemorrhage were associated with 30-day readmission.

Introduction: Endovascular treatment (EVT) is a widely proven method to treat patients diagnosed with intracranial large vessel occlusion. In order to ensure patients safety prior to and during EVT, preprocedural intubation has been adopted in many centers as a means for airway protection and immobilization. However, the correlation between site of vessel occlusion, need for intubation, and outcomes, has not yet been established. Methods: Through the utilization of a prospectively collected database at a comprehensive stroke center between 2012-2020, demographics, co-morbid conditions, intracerebral hemorrhage, mortality rate, and functional independence outcomes were examined. The outcomes and sites of occlusion between patients receiving mechanical thrombectomy (MT) treated while intubated versus those treated under conscious sedation (CS) were compared. Results: Out of 625 patients treated with MT, a total of 218 (34.9%) were treated while intubated (average age 70.3 ± 13.7, 37.2% women), and 407 (65.1%) were treated while under CS (average age 70.3 ± 13.7, 47.7% women); see Table 1 for baseline characteristics and outcomes. A higher number of patients requiring intubation had an occlusion in the basilar versus those only requiring CS. No differences were noted in regard to the proportion of patients receiving intubation or CS when treated for RMCA, LMCA, or internal carotid artery occlusions. Conclusion: Intubation + MT was associated with significantly worsened outcomes in regard to recanalization rates, functional outcome, and mortality. In anterior circulation strokes, intubation in RMCA patients were found to have poorer clinical outcome. Higher rates of intubation were also found to be needed in patients with basilar occlusions. Further research is required to determine whether site of occlusion dictates the need for intubation, and whether intubation allows for favorable outcome between R and LMCA occlusions.

Background: Hematoma expansion (HE) is an important therapeutic target in intracerebral hemorrhage. Recently proposed HE definitions have not been validated, and no previous definition has accounted for withdrawal of care (WOC). Objective: To compare conventional and revised definitions of hematoma expansion (HE), while accounting for WOC. Methods: We analyzed data from the ATACH-2 trial, comparing revised definitions of HE incorporating intraventricular hemorrhage (IVH) expansion to the conventional definition of “≥6 mL or ≥33%”. The primary outcome was modified Rankin Scale of 4-6 at 90-days. We calculated the incidence, sensitivity, specificity, positive and negative predictive values, and c- statistic for all definitions of HE. Definitions were compared using non-parametric methods. Secondary analyses were performed after removing patients who experienced WOC. Results: Primary analysis included 948 patients. Using the conventional definition, the sensitivity was 37.1% and specificity was 83.2% for the primary outcome. Sensitivity improved with all three revised definitions (53.3%, 48.7%, and 45.3%, respectively), with minimal change to specificity (78.4%, 80.5%, and 81.0%, respectively). The greatest improvement was seen with the definition “≥6 mL or ≥33% or any IVH”, with increased c -statistic from 60.2% to 65.9% (p < 0.001). Secondary analysis excluded 46 participants who experienced WOC. The revised definitions outperformed the conventional definition in this population as well, with the greatest improvement in c -statistic using “≥6 mL or ≥33% or any IVH” (58.1% vs 64.1%, p < 0.001). Conclusions: HE definitions incorporating intraventricular expansion outperformed conventional definitions for predicting poor outcome, even after accounting for care limitations.

Background: Revascularization of subacute or chronic internal carotid artery occlusion is technically feasible in some patients but carotid revascularization procedure needs to be optimized to improve the clinical success of the procedure. Objective: To describe our experience using intravascular ultrasound (IVUS) as adjunct to carotid revascularization procedure in patients with subacute or chronic internal carotid artery occlusion. Materials and Methods: Endovascular recanalization was attempted in 7 patients with symptomatic internal carotid artery occlusions between 3 and 11 days of symptoms onset. Distal protection device was deployed in all the patients followed by advancement of IVUS catheter (Eagle Eye Gold, 20 MHZ Digital, s5 Imaging System, Volcano Corp.) to obtain gray-scale and virtual histology (VH) images at regions of interest. IVUS images used to categorize occlusion content as: dark green- fibrous; yellow/green- fibrofatty; white- calcified; red- necrotic lipid core plaque on images. Intravascular thrombus was diagnosed an echolucent, homogeneous, well-delineated, diaphragm-like intraluminal structure. Results: The occlusion was recanalized successfully in all of 7 patients with median age 67.4±7.5 years. IVUS demonstrated intravascular thrombus in 5 of 7 patients. Fibrous and fibrofatty constituents of plaque were seen in 5 of the 7 patients in whom VH was done. Calcification and lipid necrotic core each were seen in 3 of 5 patients.5 patients with large thrombus burden on IVUS were treated using aspiration thrombectomy. Six of seven patients underwent stent placement and one patient underwent primary angioplasty. 5 of 7 patients had modified Rankin Scale of 0-2 at follow up (3 weeks to 4 months post procedure). Conclusions: IVUS provided valuable information to optimize carotid revascularization procedure in patients with subacute or chronic internal carotid artery occlusion.

Background: It remains unclear whether there is any improvement in outcomes of patients with intracerebral hemorrhage over the last decade. Objective: To determine trends pertaining in-hospital outcomes in patients with intracerebral hemorrhage using nationally representative data. Methods: We determined the national estimates of intracerebral hemorrhage admissions from 2005 to 2014 and associated in-hospital outcomes, length of stay, mortality, and cost incurred using the Nationwide Inpatient Survey (NIS) data. The NIS is the largest all-payer inpatient care database in the US and contains data from 986 hospitals approximating a 20% stratified sample of US hospitals. Outcome was classified as none to minimal disability, moderate to severe disability, and death based on discharge destination. Results: In the 10-year period, there were 70,637 admissions for intracerebral hemorrhage (annual estimate 80804 in 2005 to 109930 in 2014). There was a significant reduction in in-hospital mortality in patients with intracerebral hemorrhage from 30% to 23% (trend test, p < 0.0001). There was a trend towards increase in proportion of patients with moderate to severe disability (trend test, p < 0.097). The mean length of hospitalization increased from 8.58 days to 9.23 days (trend test, p < 0.0001) and cost of hospitalization increased from $50532.1 to $110932.1 (trend test, p < 0.0001). Conclusions: The mortality in patients with intracerebral hemorrhage has decreased but there is increased rates of moderate to severe disability, length of hospitalization, and hospitalization cost over the last decade.

Background: Avoidance of readmission is linked to improved quality of care, reduction in cost, and is a desirable patient-centered outcome. Nationally representative readmission metrics for patients with acute ischemic stroke treated with intravenous thrombolytic treatment (IV-tPA) are unavailable to date. Such estimates are necessary for benchmarking performance. Objectives: To identify US nationwide estimates and a temporal trend for 30-day hospital readmissions. Methods: We identified the cohort by year-wise analysis of the Nationwide Readmissions Database between January 1, 2010, and September 30, 2015. The database represents 50% of all US hospitalizations from 22 geographically dispersed states. Participants were adult (=>18 years) patients with a primary discharge diagnosis of acute ischemic (ICD-9-CM 433.x1 and 434.x1) who were treated with thrombolytic therapy (ICD-9-CM 9910). Readmission was defined as any admission within 30 days of index hospitalization discharge. Results: Based on study criteria, 57,676 eligible patients were included (mean [SE] age, 68.7 ± 14.4 years; 48.7% were women). Thirty-day readmission rate for acute ischemic stroke patients treated with IV-tPA was 11.17 % (95%CI, 10.92 %-11.43%). On average, there was a 4.4% annual decline in readmission between 2010 and 2014, which was statistically significant for the period of investigation (odds ratio, 0.95; 95%CI, 0.94-0.97). Age ≥ 65 years (OR 1.16 P P = 0.0056), chronic lung disease (OR 1.11 P = 0.0034) and renal failure (OR 1.35 P = Conclusion: Nationally representative readmission metrics can be used to benchmark hospitals’ performance, and a temporal trend of 4.4 % may be used to evaluate the effectiveness of readmission reduction strategies.

Background: Coronavirus Disease 2019 (COVID-19) is associated with an increased risk for acute ischemic stroke but screening for COVID-19 based on clinical criteria or laboratory testing may be difficult in acute stroke evaluation. Chest computed tomographic (CT) scan may be another time-sensitive option for identification. of COVID-19 in such patients. Objective: We report our experience of incorporating chest CT scan in the initial neuroimaging protocol for evaluation of acute stroke patients. Methods: All acute stroke patients underwent chest CT scan concurrent to CT head, CT angiogram of head and neck and CT perfusion for 4 months. We identified patients who had chest CT scan findings that were suggestive of COVID-19 including bilateral, multilobar ground glass opacification with a peripheral or posterior distribution, and/or consolidation (mainly in the lower lobes). All patients subsequently underwent polymerase chain reaction (PCR) testing of nasopharyngeal swab with contact isolation until COVID-19 could be excluded. Results: A total of 224 consecutive patients (mean age 62.12 years±SD; 15.3) underwent acute stroke evaluation with a concurrent chest CT scan. The chest CT identified findings suggestive of COVID-19 in 11 (4.9%) patients. Subsequent PCR testing did not confirm the diagnosis of COVID-19 in any of the patient. Another 99 patients (44%) without any findings suggestive of COVID-19 on chest CT scan underwent PCR testing. PCR testing did not confirm the diagnosis of COVID-19 in any of the patients. Four patients (4.3%) with chest CT scan findings suggestive of COVID-19 were found to have an ischemic stroke while 7 patients (5.9%) with chest CT scan findings suggestive of COVID-19 did not have any ischemic stroke (stroke mimic). Conclusions: We found a very low yield for identifying COVID-19 in acute stroke patients by performing chest CT scan concurrent to standard acute stroke neuroimaging protocol.

Background and Purpose: We determined the rates and predictors of acute kidney injury (AKI) and renal adverse events (AEs), and effects of AKI and renal AEs on death or disability in patients with intracerebral hemorrhage. Methods: We analyzed data from a multicenter trial which randomized 1000 intracerebral hemorrhage patients with initial systolic blood pressure ≥180 mm Hg to intensive (goal 110–139 mm Hg) over standard (goal 140–179 mm Hg) systolic blood pressure reduction within 4.5 hours of symptom onset. AKI was identified by serial assessment of daily serum creatinine for 3 days post randomization. Results: AKI and renal AEs were observed in 149 patients (14.9%) and 65 patients (6.5%) among 1000 patients, respectively. In multivariate analysis, the higher baseline serum creatinine (≥110 μmol/L) was associated with AKI (odds ratio 2.4 [95% CI, 1.2–4.5]) and renal AEs (odds ratio 3.1 [95% CI, 1.2–8.1]). Higher area under the curve for intravenous nicardipine dose was associated with AKI (odds ratio 1.003 [95% CI, 1.001–1.005]) and renal AEs (odds ratio 1.003 [95% CI, 1.001–1.006]). There was a higher risk to death (relative risk 2.6 [95% CI, 1.6–4.2]) and death or disability (relative risk 1.5 [95% CI, 1.3–1.8]) at 90 days in patients with AKI but not in those with renal AEs. Conclusions: Intracerebral hemorrhage patients with higher baseline serum creatinine and those receiving higher doses of nicardipine were at higher risk for AKI and renal AEs. Occurrence of AKI was associated higher rates of death or disability at 3 months. Registration: URL: https://clinicaltrials.gov . Unique identifier: NCT01176565.

Background: The estimates of recurrent intracranial hemorrhage in the post-hospitalization period among patients treated for ruptured intracranial aneurysms are not available outside clinical trials. Objective: To determine the rates of recurrent intracranial hemorrhage related hospitalization within 3 month post-hospitalization for treatment of ruptured intracranial aneurysm in a nationwide cohort of patients admitted for subarachnoid hemorrhage (SAH). Methods: We identified all readmissions related to new SAH or intracerebral hemorrhage in the nationally representative data for all patients hospitalized for SAH using the Nationwide Readmissions Database (NRD) 2013 and 2014 who had undergone endovascular or surgical treatment. Cox proportional hazards analysis was used to assess the relative risk (RR) of recurrent intracranial hemorrhage for patients in treatment cohorts after adjusting for potential confounders. The 1-year survival was estimated for both treatment groups by using the Kaplan-Meier survival method. Results: A total of 8,619 patients with SAH were treated with either endovascular (n = 4,102, 47.6%) or surgical treatment (n =4,517; 52.4%).. The estimated 3 months recurrent intracranial hemorrhage survival was 99.4% and 98.4% in patients who underwent surgical and endovascular treatments, respectively (p=0.0024). After adjusting for age>65, and APDRG severity score, the RRs of recurrent any intracranial hemorrhage was higher with endovascular treatment (RR, 3.0; 95% confidence interval (CI), 1.4 -6.7 p=0.0052). Conclusion: Although the rates of recurrent intracranial hemorrhage related hospitalization were low among patients with ruptured intracranial aneurysms, there was a higher rate among patients treated with endovascular treatment.

Background: Acute ischemic stroke patients are at risk of acute kidney injury (AKI) due to volume depletion, contrast exposure and pre-existing co-morbid diseases. We determined the incidence and identified predictors associated with AKI in acute ischemic stroke patients. Methods: Data from the Albumin in Acute Ischemic Stroke trial (ALIAS) - I and II and Interventional Management of Stroke (IMS) - III clinical trials were pooled and analyzed in which acute ischemic stroke patients were randomized into either IV albumin, placebo, endovascular or IV thrombolytic treatment groups. Serum creatinine levels from baseline and within day 5 or discharge along with the demographic and comorbidity information was collected. AKI classification was used to ascertain severity of renal dysfunction and based on increase in serum creatinine levels from baseline, stage 1 ≥ 0.3 mg/dl (≥ 26.4umol/L) or (>1.5 to 2-fold), stage 2 (>2 to 3-fold) and stage 3 (>3-fold) were identified. We analyzed the relationship between AKI and mortality at 3 months post randomization. Results: A total of 1931 acute ischemic stroke patients (mean age 66± 13 (SD) years; 1024 were men) were analyzed. Any increase in serum creatinine was seen in 691 (35.8%, 95% CI 30%-40%) and AKI was seen in 68 (3.5%, 95% CI 3%-4%) of 1931 patients. Severity of AKI was grade I, II, III in 2.1 %, 0.4%, and 0.1% patients, respectively. The risk of AKI was not higher between those who either underwent CT angiography (2% compared with 4.2%, RR 0.5, 95% CI 0.3-0.8, p=0.02) or endovascular treatment (1.9% compared with 4.1%, RR 0.4, 95% CI 0.2-0.8, p=0.0096). Patients with preexisting hypertension (4.3% compared to 1.5%, RR 2.8, 95% CI 1.3-5.7, p=0.006) and preexisting renal disease (9.1% compared to 3.0%, RR 3.1, 95% CI 1.8-5.3, p=0.006) had higher risk of AKI. Mortality at 3 months was significantly higher among patients with AKI (27% compared with 15%, RR 1.8, 95% CI 1.2-2.7, p=0.0083). Conclusions: The incidence of AKI in acute ischemic stroke patients was low and was not higher in patients who underwent CT angiogram or those who received endovascular treatment. Occurrence of AKI increased mortality at 3 months among acute ischemic stroke patients.

Background: Viz.ai artificial intelligence (AI) software utilizes AI powered large vessel occlusion (LVO) detection technology which automatically identifies suspected LVO through CT angiogram (CTA) imaging and alerts on-call stroke teams. We performed this analysis to determine if utilization of AI software can reduce the time interval between CTA at a primary stroke center (PSC) and arrival time at a comprehensive stroke center (CSC). Methods: We compared time interval between CTA and time of arrival for all LVO transfer patients from a single spoke PSC to our CSC prior to (Feb. 2017 to Nov. 2018) and after (Nov. 2018 to May 2019) incorporating Viz.ai. Using a prospectively collected stroke database at a CSC, demographics, transfer time (CTA time to time of arrival at CSC), modified Rankin Scale at discharge (mRS dc), mortality rate at discharge, length of stay (LOS) in hospital and neurological ICU, and intracranial hemorrhage rates were examined. Results: There were a total of 43 patients during the study period (average age 70.77 ± 12.54 yrs., 51.16% women). Analysis of 28 patients from the pre-Viz.ai (average age 71.64 ± 12.28 yrs., 46.4% women), and 15 patients from the post-Viz.ai (average age 69.13 ± 13.29 yrs., 60.0% women); see Table 1 for comparison of baseline characteristics and outcomes. Following implementation of Viz.ai, CTA time at PSC to time of arrival at CSC was significantly reduced by an average of 66 min. (mean CTA to time of arrival, 171 min. vs 105 min; P= 0.0163); significant reductions were also noted in the overall LOS (9.7 days vs 7.2 days; P= 0.0324) and LOS in the neurological ICU (6.4 days vs 2.9 days; P= 0.0039). Conclusions: The incorporation of Viz.ai was associated with a significant improvement in transfer times for LVO patients as well as a significant reduction in the overall hospital LOS and LOS in the neurological ICU. More extensive studies are warranted to expand on the ability of AI technology to improve transfer times and outcomes for LVO patients.

Importance: Golf is played by about 25 million people in United States and may reduce the risk of cardiovascular diseases by providing regular exercise and stress relief. Objective: To test whether playing golf regularly reduces the risk of myocardial infarction (MI), stroke and/or death among elderly persons. Design, Settings, and Participants: We analyzed data from the Cardiovascular Health Study (CHS), an NHLBI-funded the population-based, prospective observational cohort study of risk factors for cardiovascular disease in adults 65 years or older. Starting in 1989, and continuing through 1999, participants underwent annual extensive clinical examinations and 6 monthly clinic visits, and once clinic visits ended, participants were contacted by phone to ascertain occurrence of cardiovascular events. Golf status was inquired at baseline and longitudinal follow-up was conducted for a mean (SD) of 13 (6.2) years. Persons who played golf for at least 1 month per year were considered as regular golf players. We performed Cox proportional hazards analysis to determine the effect of playing golf on incident MI, stroke, and death during follow up after adjusting for potential confounders. Results: The mean (SD) age of the entire cohort (n = 5888) was 72.8 (5.6) years; 2466 (41.9%) were men. Golf was played regularly by 384 persons. During follow-up, 31 (8.1%) participants had stroke and 38 (9.9%) had MI. Overall mortality rate was 1,115 deaths per 100,000 population. There was a significantly lower rate of death among persons who played golf regularly compared with those who did not (24.6% vs 15.1%). There was no difference in the rates of MI or stroke among those who played golf regularly. In the multivariate analysis, death was less likely among persons who played golf regularly (HR 0.6, 95% CI (0.4-0.7; p- Conclusions: In this large, population-based study, elderly persons who played golf were at lower risk of death. However, the protective effect of playing golf was not related to reduction in cardiovascular events.

Introduction: Cilostazol, a selective inhibitor of phosphodiesterase 3, may reduce symptomatic vasospasm and associated cerebral ischemia and improve outcomes in patients with aneurysmal subarachnoid hemorrhage (aSAH) due to its anti-platelet, anti-proliferative, and vasodilatory effects. Due to recent publication of randomized controlled clinical trials, a meta-analysis was performed to identify the common treatment effect. Methods: We performed a meta-analysis of four randomized controlled clinical trials. The primary endpoint of interest was cerebral ischemia related to vasospasm. Secondary endpoints were angiographic vasospasm, new cerebral infarct, mortality, and death or disability at the 90 days following randomization. Using random-effects models with study as a random effect, relative risks (RR) and 95% confidence intervals (CI) were generated Results: A total of 405 subjects (200 randomized to oral cilostazol 100 mg twice per day) were included in the meta-analysis. The proportion of subjects with cerebral ischemia related to vasospasm was significantly lower in those who were assigned to cilostazol treatment (RR 0.46; 95% CI 0.21-1.00; p< 0.050) without any heterogeneity between the trials (Cochran’s Q statistic 1.52, df 2; P = .468, I 2 =0.0%). The proportion of subjects who had new cerebral infarction was significantly lower in subjects who were assigned to cilostazol treatment (RR 0.40, 95% CI 0.32-0.49, p=0.0009). There was a lower rate of death or disability at 90 days in subjects who were assigned to cilostazol treatment (RR 0.44, 95% 0.28-0.70, p=0.011) without any heterogeneity between the trials (Cochran’s Q statistics 1.49, df 3; P = .685, I 2 =0.0%). The proportion of subjects who had any adverse events was not significantly different in subjects who were assigned to cilostazol treatment (RR 1.24, 95% 0.68-2.25, p=0.26). Conclusion: The reduction in rates of cerebral ischemia related to vasospasm and death or disability at follow-up support further evaluation of oral cilostazol in patients with aSAH in a phase III large randomized clinical trial.

Background: We performed this study to determine the predictors of length of hospitalization in patients admitted with intracerebral hemorrhage using nationally representative data. Methods: We used the National Inpatient Sample (NIS) from 2010 to 2015 to assess the factors associated with length of stay in patients admitted with intracerebral hemorrhage using (ICD-9 CM diagnosis-related code 431). Patients who were transferred from another acute hospital or died within 2 days of admission were excluded. All variables pertaining to hospitalization were compared in 4 quartile groups on basis of length of hospital stay distribution (≤3, 4-6, 7-10 and ≥11 days) and median length of stay was calculated. The predictors of hospital stay exceeding the median length of stay were identified using multivariate logistic regression. Results: A total of 296,792patients were admitted with the diagnosis of intracerebral hemorrhage during the study period. The length of hospitalization was (≤3, 4-6, 7-10 and ≥11 days in 79,008 (26.5%), 89,019 (30.0%), 55,555 (18.7%) and 73,211 (24.6%) patients, respectively; median length of stay for the cohort was 6 days. In the multivariate logistic regression analysis, the following clinical factors were associated with length of hospitalization of ≥6 days (median): male (odds ratio [OR] 1.10), hypertension (OR 1.41 ), APRDRG severity (OR 2.87), history of alcohol use (OR 1.27 ), and in-hospital complications such as sepsis (OR 2.73), pneumonia (OR 2.30), urine tract infection (OR 2.34), pulmonary embolism (OR 1.42), and deep vein thrombosis (OR 5.06). Similarly in-hospital procedures such as craniotomy (OR 3.40), and transfusion (OR 2.09), were associated with length of hospitalization of ≥6 days. The excess hospitalization charges associated with length of hospitalization of ≥6 days was $107,915. Conclusion: Prolonged hospitalization is associated with significantly higher cost of hospitalization. The most important determinants being pre-existing medical comorbidities and potentially preventable in-hospital complications.

Introduction: The etiology and significance of diffusion weighted imaging (DWI) lesions in patients with acute intracerebral hemorrhage (ICH) remain unclear. We evaluated which factors were associated with DWI lesions, whether associated factors differed by ICH location, and whether DWI lesions were associated with functional outcomes. Methods: We pooled individual patient data from the MISTIE III trial, the ATACH-II trial, the i-DEF trial, and the ERICH study. We included only patients who underwent protocolized magnetic resonance imaging (MRI) of the brain. A poor functional outcome was defined as a modified Rankin Scale (mRS) score of 4-6 at 3-6 months. We used mixed effects logistic regression with the study database as a random effect. Results: Among 1,775 ICH patients, there were 621 (35.6%) lobar, 978 (55.9%) deep, and 148 (8.5%) infratentorial ICHs. Median time to MRI scan was 1.5 days (IQR, 1-4). DWIHLs occurred in 559 (31.5%) patients, with 190 (34.3%) in lobar ICH and 320 (57.8%) in deep ICHs. In mixed effects regression models, factors associated with DWIHLs included younger age factors associated with DWIHLs after acute ICH included younger age (OR, 0.98; 95% CI, 0.97-0.99), black race (OR, 1.59; 95% CI, 1.18-2.16), admission systolic blood pressure (SBP per 10 mm Hg, OR, 1.13; 95% CI, 1.05-1.22), cerebral microbleeds (OR, 1.71, 95% CI, 1.24-2.35), and leukoaraiosis (OR, 1.60; 95% CI, 1.14-2.25). Patients with DWIHLs had higher odds of mRS 4-6 (OR, 1.57; 95% CI, 1.24-1.99) compared to those without, after adjustment for demographics and ICH severity. In subgroup analyses, similar factors influenced DWIHLs in deep ICH. However, in lobar ICH, younger age, admission SBP, and leukoaraiosis were associated with DWIHLs. Presence of DWIHLs was independently associated with poor mRS in deep ICH but not in lobar ICH. There was no relationship between acute BP lowering and DWIHLs, regardless of location. Conclusions: In a large, heterogeneous cohort of ICH patients, our results are consistent with the hypothesis that DWIHLs represent the effects of chronic hypertensive vasculopathy and acute blood pressure elevation. Furthermore, DWIHLs portend poor prognosis after ICH, particularly in deep hemorrhages.

Introduction: Severe tortuosity of the cervical internal carotid artery distal to the stenosis may prevent successful placement of distal protection device and increase the risk of dissection and/or ischemic stroke. Objective: To assess and categorize the effects of tortuosity of the cervical internal carotid artery distal on procedural times, and peri-procedural complications in patients treated with carotid artery stent placement. Material and Methods: We analyzed the angiographic images and clinical data for a consecutive series of patients treated with stent placement over an 18-month period and graded the tortuosity as follows: Grade 0 is no vessel turns; Grade 1 (MILD) is 1 vessel turn, >90 degrees; Grade 2 (MODERATE) is 1 vessel turn, ≤90 degrees; Grade 3 (SEVERE) is 2 vessel turns, any angle; Grade 4 (SEVERE) is two vessel segments which are parallel to due to interspersed loop; Grade 5 (SEVERE) is a complete vessel loop (360 degrees). Technical complications including unsuccessful attempts to cross the stenosis with interventional devices, unutilized distal embolic protection, iatrogenic dissection, and ischemic events were ascertained. Results: A total of 80 patients were identified who underwent stent placement; mean (SD) 67.4 (8), 60 (75%) were men. Forty-three patients (53.8%) had evidence of stroke on non-invasive imaging prior to stent placement. In sixty-five cases, stent placement was performed electively (81.3%), emergently in fifteen cases (18.8%). The tortuosity was graded as 1 (46.2%), 2 (11.3%), 3 (15%), 4 (6.3%), and 5 (2.5%). Of the 80 patients, eighteen (22.5%) had severe tortuosity of grade 3 or higher. Mean procedural time (SD) was significantly greater with severe vessel tortuosity compared to mild to moderate vessel tortuosity (51.6 (6.2) versus 42.3 (5.2) minutes, p=.042). Technical complication rates were not significantly different with severe vessel tortuosity compared with mild to moderate vessel tortuosity (7% vs 9% p=.53). One intra-procedural dissection occurred in a case of severe tortuosity (grade 5). Conclusions: Severely tortuous internal carotid arteries distal to the stenosis can be seen in one fifth of patients undergoing carotid stent placement and is associated with increased procedural times.

Background: Endovascular treatment (EVT) is a widely proven method to treat patients diagnosed with intracranial large vessel occlusions (LVO); however, there has been controversy regarding the safety and efficacy of incorporating intravenous tissue plasminogen activator (IV tPA) as pretreatment for EVT. We compared the outcomes of all LVO patients treated with IV tPA + EVT versus EVT alone within 4.5 hours of stroke onset. Methods: Through the utilization of a prospectively collected endovascular database at a comprehensive stroke center between 2012-2019, variables such as demographics, co-morbid conditions, symptomatic/asymptomatic intracerebral hemorrhage (S-ICH/A-ICH), mortality rate, and good/poor outcomes in regard to modified thrombolysis in cerebral infarction score (TICI) and modified Rankin Scale assessment at discharge (mRS dc) were examined. The outcomes between patients receiving IV tPA + EVT upon admission and patients that underwent EVT alone were compared. Results: Out of 588 acute ischemic stroke patients treated with EVT, a total of 189 met the criteria for the study (average age 70.44 ± 12.90 years, 42.86% women). Analysis of 109 patients from the EVT + IV tPA (average age 68.17 ± 14.28 years, 41.28% women), and 80 patients from the EVT alone was performed (average age 73.54 ± 9.84 years, 45.00% women); see Table 1 for baseline characteristics and outcomes. Four patients (5.0%) in the EVT alone group experienced S-ICH versus 15 patients (13.8%) in the IV tPA + EVT group (p=.0478); significant increases were also noted in the length of stay for patients treated with IV tPA (8.2 days vs 11.0 days; P=.0055). Conclusion: IV tPA in addition to EVT was associated with an increase in the rate of ICH in LVO patients treated within 4.5 hours and in patients’ length of stay. Further research is required to determine whether EVT treatment alone in LVO patients treated within 4.5 hours is a more effective option.

Background: Cigarette smoking is a well-known risk factor for ischemic and hemorrhagic stroke. We evaluated the impact of smoking status on hematoma expansion and clinical outcome in patients with primary intracerebral hemorrhage (ICH). Methods: This is a post hoc exploratory analysis of Antihypertensive Treatment at Acute Cerebral Hemorrhage(ATACH)-2 trial. Patients with ICH were randomized into intensive blood pressure lowering(SBP: Results: Of total of 914 patients in the trial with known smoking status, 439 (48%) patients were ever-smokers (264 current smokers and 175 former smokers). Current and former smokers were younger and more likely to be male. There was no difference in the baseline Glasgow Coma Scale(GCS) score and initial hematoma size based on smoking status. Ever-smokers had higher rate of thalamic hemorrhage (42% vs 34%) and intraventricular hemorrhage (29% vs 23%); this rate was highest among former smokers (49% and 35%, respectively). Ever-smokers had higher rate of hematoma expansion in 24 hour [adjusted RR (95% CI): 1.46; (1.05 -2.03)] compared to non-smokers after adjusting for confounding factors. There was no significant difference in the rate of death and disability at 90 days between the two groups [adjusted RR; (95% CI): 1.18; (0.93 -1.50)]. Conclusions: Our analysis demonstrates cigarette smoking as an independent predictor for hematoma expansion. There was no significant difference in death and disability based on smoking status.

Background and purpose: We aimed to highlight temporal trajectories of systolic blood pressure (SBP) in patients with acute intracerebral hemorrhage (ICH) to investigate the clinical relevance of heterogeneity in responses to blood pressure lowering therapy. Methods: A post-hoc analysis of ATACH-2 trial, in which ICH patients were randomly assigned to intensive or standard SBP lowering with intravenous administration of nicardipine. Using data for all 1000 patients enrolled from 110 clinical sites, temporal changes of hourly maximum SBP up to 24 hours after randomization were analyzed with the group-based trajectory modeling (GBTM). Model selection was mainly based on the Bayesian Information Criteria. The primary outcome was death or disability (modified Rankin Scale score 4-6) at 3 months. Secondary outcomes included hematoma expansion within 24 hours and acute kidney injury (AKI). AKI was defined as an increase in serum creatinine by ≥0.3 mg/dl or to ≥1.5 times baseline within 48 hours. The outcomes were compared between the trajectory groups using multivariable logistic models with random-effects by clinical sites. Results: Of the analyzed 1000 patients, death or disability, hematoma expansion, and AKI were encountered in 367, 161, and 101 patients, respectively. GBTM revealed 4 SBP trajectory groups: early response-low SBP (38.2%), moderate SBP (16.8%), delayed response-low SBP (14.2%), and high SBP (30.8%). Nicardipine dosage was highest in the delayed response-low SBP group, 81.7% of which were from the intensive SBP lowering group. The risk of death or disability was higher only in the delayed response-low SBP group (adjusted odds ratio [aOR] 2.86; 95% confidence interval [CI] 1.66-4.93) than in the early response-low SBP group. The risk of hematoma expansion was not significantly different among the groups. The delayed response-low SBP group had higher risk of AKI (aOR 2.78; 95% CI 1.46-5.31; reference, the early response-low SBP group). Conclusions: An SBP trajectory group with delayed SBP lowering despite intensive treatment was associated with increased risk of death or disability at 3 months. Resistance to intensive SBP lowering may predict poor clinical outcomes, and intensive SBP control in these cases will increase the risk of AKI.

Background: Carotid revascularization procedure, carotid endarterectomy (CEA) and carotid stent placement (CAS), are some of the most common procedures performed in United States and expected to change due to wider adoption of CAS. We performed this study to determine the changes in utilization of CEA and CAS in United States using nationally representative data. Methods: We used the National Inpatient Sample (NIS) from 2005 to 2014 to assess the changes in utilization of CEA and CAS over last 10 years in patients with symptomatic and asymptomatic carotid artery stenosis. NIS is the largest all payer dataset that includes diagnoses, admissions and discharge, demographics, and outcomes data of patients admitted to short stay non-Federal hospitals in the United States. We analyzed patterns of changes in utilization in various subsets of patients with carotid artery stenosis. Results: A total of 1,186,182 patients underwent carotid revascularization procedures during study period; 1,032,148 (87.1%) and 154,035 (12.9%) were CEA and CAS, respectively. The overall carotid revascularization procedures decreased over last 10 years (11.1% in 2005 to 8.4%in 2014, trend test p Conclusion: Although CAS is increasing in a disproportionate manner within patient subgroups in United States, overall carotid revascularization procedures have decreased for unclear reasons.

Background: Due to higher rates of 1-month stroke and death with Wingspan intracranial stent placement observed in SAMMPRIS, FDA announced a more limited indication for Wingspan stent. We compared the results of intracranial stent placement with best medical treatment in patients who met “on label” criteria with those who were treated as “off label”. Methods: Patients recruited in the SAMMPRIS trial were classified as “on label” if: age 22 to 80 years, stenosis of 70%-99%, baseline modified Rankin Scale score ≤ 3, ≥2 ischemic events in the vascular territory of the stenotic lesion with at least 1 ischemic event while on medical therapy, and stent placement ≥8 days after the last stroke. All other patients were classified as “off label”. The primary endpoint was any stroke or death occurring within 30 days of enrollment, or any stroke or death within 30 days of any revascularization procedure of the qualifying symptomatic intracranial artery done during follow-up, OR an ischemic stroke in the territory of the symptomatic intracranial artery from day 31 after study entry to completion of follow-up. Results: A total of 31 (6.87%) among 451 recruited patients met the “on label” criteria. The relative risk of primary endpoint was lower in “on label” patients treated with stent placement compared with best medical treatment (RR 0.8, 95 % CI 0.2 - 2.9) but higher in “off label” patients (RR 1.65, 95 % CI 1.0-2.4). Primary endpoint was seen in 20% and 23.4% of patients treated with stent placement in “on label” and “off label” patients, respectively. Primary endpoint was seen in 25% and 14.2% of patients treated with best medical treatment in “on label” and “off label” patients, respectively. In Cox Proportional Hazards analysis with primary endpoint as dependent variable, the interaction between “on label” and treatment (stent versus best medical treatment) was not significant (p=0.6713). Conclusion: The new FDA “on label” criteria may identify a group of who may benefit from intracranial stent placement due to higher risk of primary endpoint in those treated with best medical treatment. However, the criteria appears to be very stringent and only a small proportion of patients may meet the “on label” criteria.

Background: Mechanical thrombectomy (MT) is a proven method of treating patients with acute ischemic stroke (AIS) from a large vessel occlusion. However, there has been controversy regarding the safety and efficacy of incorporating acute intracranial stenting in addition to standard MT especially after the WEAVE trial results which showed a significant increase in stroke and hemorrhage in patients receiving wingspan stenting within 7 days of index ischemic event. We compared the outcomes of all AIS patients treated with acute intracranial stenting + MT versus MT alone. Methods: Through the utilization of a prospectively collected endovascular database at a comprehensive stroke center between 2012-2019, variables such as demographics, co-morbid conditions, symptomatic intracerebral hemorrhage (ICH), mortality rate at discharge, and good/poor outcomes in regard to modified thrombolysis in cerebral infarction score (TICI) and modified Rankin Scale at discharge (mRS dc) were examined. The outcomes between patients receiving acute intracranial stenting + MT and patients that underwent MT alone were compared. Results: There were a total of 439 AIS patients who met criteria for the study (average age 70.38 ± 13.46 years; 45.6% were women). Analysis of 36 patients from the acute stenting + MT group (average age 66.72 ± 13.17 years; 30.6% were women), and 403 patients from the MT Alone group (average age 70.71 ± 13.45 years; 46.9% were women); see Table 1 for baseline characteristics and outcomes. Three patients (8.3%) in the acute stenting + MT group experienced ICH versus forty-four patients (10.9%) in the MT alone group (P=0.631); no significant increases were noted in length of stay (9.08 days vs 9.84 days; P=0.620) or good mRS scores at dc (P=0.636). Conclusion: Acute intracranial stenting in addition to MT was not associated with an increase in ICH rates, overall length of stay, or poor outcome upon discharge of patients. Prospective studies are recommended.

Background: Intracerebral hemorrhage (ICH) is associated, with high rates of mortality, and long-term disability. We investigated the predictive values of the Glasgow Coma Scale (GCS) and National Institutes of Health Stroke Scale (NIHSS) in the prognosis of mortality and functional outcome in patients with ICH. Methods: A total of 1000 patients recruited in a clinical trial with acute were assessed using GCS and NIHSS at admission. Then, the receiver operating characteristic (ROC) curves were established, and the area under the curves of these 2 scoring systems was compared. The primary outcome was death or disability (modified Rankin scale (mRS) score of 4 to 6, on a scale ranging from 0 [no symptoms] to 6 [death]) at 3 months after randomization, as ascertained by an investigator who was unaware of the treatment assignments. Results: The area under the curve of GCS and NIHSS was 0.660 (95% confidence interval: 0.593-0.727) and 0.708 (95% confidence interval: 0.640-0.755), respectively, for predicting disability among survivors. The area under the curve was 0.655 (95% confidence interval: 0.621-0.688) and 0.788 (95% confidence interval: 0.759-0.817), respectively for prediction of 3-months death or disability among all patients with ICH. The GCS predicted 3-month disability among survivors with a sensitivity of 68.7% and a specificity of 57.7%, and the NIHSS predicted 3-month disability with a sensitivity of 74.6% and a specificity of 62.3%. The GCS predicted 3-month death or disability among all patients with a sensitivity of 60.5% and a specificity of 66.5%, and the NIHSS predicted 3-month death or disability with a sensitivity of 80.1% and a specificity of 66.8%. NIHSS (P Conclusions: GCS and NIHSS scales have good predictive values for the prognosis of patients with ICH as regards of mortality and disability. The NIHSS is more accurate than the GCS in predicting death or disability in patients with ICH.