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Introduction: Acute ischemic stroke (AIS) may be the first sign of occult cancer. We aimed to better define the incidence of cancer in the year after AIS and to identify clinical factors associated with new cancer diagnoses. Methods: This was a retrospective cohort study using data from the Cornell Acute Stroke Academic Registry (CAESAR) on patients hospitalized at our center with AIS from 2011-2015. Patients with history of cancer were excluded. Through automated electronic data capture and manual abstraction of inpatient and outpatient medical records, we collected data on patients’ demographics, comorbidities, presentation, radiographic characteristics, stroke subtype, and clinical outcomes. Patients were followed for 1 year after the index AIS for a new diagnosis of pathologically-confirmed cancer. Cox hazards regression adjusting for the competing risk of death was used to evaluate associations between clinical factors and incident cancer. Factors significantly associated in multivariable analysis were entered into a risk stratification score, and this score’s discriminatory ability was evaluated by Harrell’s C-statistic. Results: After excluding 253 patients with history of cancer, this analysis included 963 patients with AIS. During a mean follow-up of 222 days, 16 patients (1.7%; 95% CI, 1.0-2.7%) were diagnosed with cancer. The most common cancers were lung (n=7) and leukemia (n=4) and the median time to cancer diagnosis was 13 days (IQR, 7-194 days). Among patients with cryptogenic stroke, the 1-year cancer incidence rate was 1.7% (95% CI, 0.6-3.7%). Clinical factors associated with incident cancer in multivariable analysis were venous thromboembolism during the AIS hospitalization (HR, 12.5; 95% CI, 3.3-47.0), unexplained weight loss within 6 months (HR 11.7; 95% CI, 3.3-42.0), and three-territory acute infarcts (HR, 4.1, 95% CI, 1.3-13.4). These factors were used to create a clinical score that had a C-statistic of 0.7 (95% CI, 0.5-0.8). Conclusions: In a large urban cohort of AIS, the estimated 1-year incidence of first-ever cancer was 1.7%. Unexplained weight loss, concomitant venous thromboembolism, and three-territory acute infarction pattern may serve as clues to occult cancer with AIS.

Introduction: Dissection of a cervical artery has been well described as a cause of ischemic stroke in the young. The role of dissection as a cause of stroke among older adults is less clear, but there are no obvious reasons why older patients would have less of a predisposition to dissection than younger patients. Hypothesis: We hypothesized that the incidence of dissection-related ischemic stroke would remain constant across age. Methods: We used inpatient discharge data included in the 2012-2015 releases of the National Inpatient Survey (NIS). We used previously validated ICD-9-CM codes to identify adults who were hospitalized with ischemic stroke and a concomitant diagnosis of either carotid- or vertebral-artery dissection. We compared the prevalence of concomitant dissection among stroke hospitalizations across patient subgroups defined by age. Survey weights provided by the NIS were used to calculate nationally representative estimates. Population estimates from the U.S. census were used to calculate the incidence of hospitalization with stroke and concomitant dissection per million person-years. Results: From 2012-2015, there were 17,325 hospitalizations with ischemic stroke and a concomitant dissection in the US. The prevalence of cervical-artery dissection among stroke hospitalizations was highest among those under 40 years of age and gradually decreased across increasing 10-year age intervals (Figure 1A). On the other hand, the overall incidence of hospitalization for stroke and concomitant dissection increased with increasing age (Figure 1B). Conclusions: In a nationally representative sample, we found that cervical-artery dissection accounts for a greater proportion of ischemic strokes among younger patients, but the absolute incidence of dissection-related stroke increases with age.

Background: Evidence of visceral infarction is often found in patients with acute ischemic stroke, and appears to be more common among patients with embolic stroke subtypes. It remains uncertain whether there exists a relationship between visceral infarction and functional outcomes among patients with stroke. Methods: Among patients with acute ischemic stroke enrolled in the Cornell AcutE Stroke Academic Registry (CAESAR) from 2011 through 2016, we included those with a contrast-enhanced abdominal computed tomographic scan within 1 year of admission. Our outcome was ambulatory status at discharge from the acute stroke hospitalization, defined as walking without assistance, walking with assistance, and unable to walk. We used ordinal logistic regression to examine the association between visceral infarction and discharge ambulatory status after adjustment for demographics, stroke risk factors, stroke severity (NIH Stroke Scale score) and stroke subtype. Results: Among 2,116 ischemic stroke patients registered in CAESAR from 2011-2016, 228 had contrast-enhanced abdominopelvic computed tomographic imaging, of whom 40 (18%) had evidence of visceral infarction. Among the 188 patients without visceral infarction, 125 (66%) patients were discharged walking without assistance, 34 (18%) patients could walk with assistance, and 29 (15%) patients could not walk. In comparison, among the 40 patients with visceral infarction, 18 (45%) patients were discharged walking without assistance, 9 (23%) patients could walk with assistance, and 13 (33%) patients could not walk. After adjustment for demographics, stroke risk factors, stroke severity and stroke subtype, the presence of visceral infarction was associated with a worse ambulatory status (global OR for better ambulatory status, 0.3; 95% CI, 0.1-0.8). Conclusions: We found that the presence of visceral infarction, which is often incidentally detected on imaging among stroke patients, was associated with poor functional outcomes at the time of hospital discharge. These findings suggest that such incidental findings are not benign and are at the least a marker of poor outcomes.

Background: Majority of aneurysmal subarachnoid hemorrhage (SAH) survivors develop cognitive dysfunction. To better understand the underlying mechanisms and develop treatments, predictive animal models are required. We carried out a detailed physiological and cognitive characterization of pre-chiasmatic cistern (PC) and cisterna magna (CM) SAH models in mice. Methods: SAH was induced by arterial blood injection into the PC (40 μl) or CM (60 μl) in C57BL6/J mice (male, 25g). Controls received normal saline. Cerebral blood flow (CBF) was imaged using laser speckle flowmetry during and for 60 min after SAH. Intracranial pressure (ICP) and blood pressure (BP) were monitored to calculate cerebral perfusion pressure (CPP). Neurological and cognitive function was assessed 3 weeks after the injection, using pole, novel object recognition, Y maze and Morris water maze tests. Results: Mortality was 10% after PC and 4% after CM SAH. In both groups, CPP decreased from about 65 mmHg to less than 10 mmHg immediately after the injection, and recovered to 40 mmHg within 10 min after PC (n=8) and 7 min after CM (n=8) SAH (Fig A). In both groups, CBF was severely reduced to ~20% of baseline in both hemispheres immediately after SAH. CBF recovered to >40% within 5 min after PC and 2 min after CM SAH (Fig A). In saline controls (n=5 in PC and CM each), CPP and CBF changes were much milder and shorter-lasting. Compared with controls (n=12), PC SAH mice (n=12) performed significantly worse in a subset of sensorimotor and cognitive tests for up to 3 weeks (Fig B). CM SAH did not significantly impact neurological function. Conclusions: Pre-chiasmatic cistern but not cisterna magna SAH model reproduces cognitive dysfunction observed in patients with low mortality and high reproducibility in mice.