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Background Endovascular therapy for acute ischemic stroke has revolutionized clinical care for patients with stroke and large vessel occlusion, but treatment remains time sensitive. At our stroke center, up to half of the door‐to‐groin time is accounted for after the patient arrives in the angio‐suite. Here, we apply the concept of a highly visible timer in the angio‐suite to quantify the impact on endovascular treatment time. Methods This was a single‐center prospective pseudorandomized study conducted over a 32‐week period. Pseudorandomization was achieved by turning the timer on and off in 2‐week intervals. The primary outcome was angio‐suite‐to‐groin time, and secondary outcomes were angio‐suite‐to‐intubation time, groin‐to‐recanalization time, and 90‐day modified Rankin scale. A stratified analysis was performed based on type of anesthesia (ie, endotracheal intubation versus not). Results During the 32‐week study period, 97 mechanical thrombectomies were performed. The timer was on and off for 38 and 59 cases, respectively. The timer resulted in faster angio‐suite‐to‐groin time (28 versus 33 minutes; P=0.02). The 5‐minute reduction in angio‐suite‐to‐groin was maintained after adjusting for intubation status in a multivariate regression (P=0.02). There was no difference in the 90‐day modified Rankin scale between groups. The timer impact was consistent across the 32‐week study period. Conclusions A highly visible timer in the angio‐suite achieved a meaningful, albeit modest, reduction in endovascular treatment time for patients with stroke. Given the lack of risk and low cost, it is reasonable for stroke centers to consider a highly visible timer in the angio‐suite to improve treatment times.

Background Acute endovascular revascularization for isolated internal carotid occlusion without tandem intracranial occlusion has been proposed to prevent early neurologic deterioration (END) and improve outcome, but has not been shown to be more effective than medical therapy. We aimed to evaluate prognosis with initial medical therapy alone, and also performed a systematic review to put these results in a broader context. Methods We performed a retrospective cohort study of patients admitted over a 2‐year period with acute stroke/transient ischemic attack due to isolated internal carotid artery occlusion. Subjects with tandem intracranial occlusion or Alberta Stroke Program Early CT Score (ASPECTS) ≤5 were excluded. The primary outcome was END within 48 hours (National Institute of Health Stroke Scale [NIHSS] increase ≥4 persisting for ≥24 hours). Secondary outcomes included discharge NIHSS and disposition. We also performed a systematic review and meta‐analysis of published studies along with the data from our cohort. Results Twenty‐three patients met our inclusion criteria. Median age was 69 years, initial Alberta Stroke Program Early CT Score 10, and NIHSS score 3. END attributed to recurrent ischemia occurred in 5/23 patients (22%, 95% CI: 7%–44%). At discharge, 78% had a favorable outcome with a median NIHSS of 2 (interquartile range 1–3). END appeared more frequent in those with higher baseline NIHSS. In our systematic review, 7 prior studies met our inclusion criteria. END occurred in 17% (95% CI: 12%–23%) of patients, 18% with medical therapy versus 13% with endovascular therapy, with substantial heterogeneity among studies. Conclusion In patients with acute stroke or transient ischemic attack due to isolated internal carotid occlusion, END is relatively common (occurring in about 1 out of 6 patients). Further research is needed to evaluate the roles of maximal medical management or acute endovascular thrombectomy in these patients.

Background The GWTG (Get With The Guidelines)‐Stroke registry supports clinical research and quality improvement projects that often rely on past medical history elements, the reliability of which remains largely unknown. Here, we evaluated the reliability of specific past medical history elements in a local GWTG–Stroke data set, with particular attention to calculating the CHA2DS2‐VASc score. Methods and Results A single‐center cohort was identified by querying the Hospital of the University of Pennsylvania’s GWTG IQVIA Registry Platform for patients admitted with acute ischemic stroke between January 2017 and December 2020, with a previously known history of atrial fibrillation. Demographics and previously known medical history elements were retrieved from the registry to calculate the CHA2DS2‐VASc score. Five neurologists abstracted the same medical history elements from the health records. The κ statistics quantified the reliability of medical history elements and CHA2DS2‐VASc score. Four hundred fifty‐three patients with acute ischemic stroke and previously known atrial fibrillation were included in the cohort. In comparison with manual reabstraction, registry‐based medical history elements were only moderately reliable: congestive heart failure (κ=0.53), hypertension (κ=0.42), diabetes (κ=0.80), prior stroke (κ=0.45), and vascular disease (κ=0.48). However, leveraging these variables to calculate the CHA2DS2‐VASc score was more reliable (κ=0.73). Conclusions Previously known medical history elements in the GWTG‐Stroke registry were only modestly reliable in this single‐center study, suggesting caution should be exercised when relying on any individual history elements in registry‐based research. Combining these variables to calculate the CHA2DS2‐VASc score was somewhat more reliable. Multicenter data are needed before assuming generalizability.

Background and Purpose: Dual antiplatelet therapy (DAPT), compared to single antiplatelet therapy (SAPT), lowers the risk of stroke or death early after TIA and minor ischemic stroke. Prior trials excluded moderate to severe strokes, due to a potential increased risk of bleeding. We aimed to compare in-hospital bleeding rates in SAPT and DAPT patients with moderate or severe stroke (defined by NIHSS ≥4).Methods: We performed a retrospective cohort study of ischemic stroke over a 2-year period with admission NIHSS ≥4. The primary outcome was symptomatic intracranial hemorrhage (ICH) with any change in NIHSS. Secondary outcomes included systemic bleeding and major bleeding, a composite of serious systemic bleeding and symptomatic ICH. We performed analyses stratified by stroke severity (NIHSS 4–7 vs. 8+) and by preceding use of tPA and/or thrombectomy. Univariate followed by multivariate logistic regression evaluated whether DAPT was independently associated with bleeding.Results: Of 377 patients who met our inclusion criteria, 148 received DAPT (39%). Symptomatic ICH was less common with DAPT compared to SAPT (0.7 vs. 6.4%, p < 0.01), as was the composite of major bleeding (2.1 vs. 7.6%, p = 0.03). Symptomatic ICH was numerically less frequent in the DAPT group, but not statistically significant, when stratified by stroke severity (NIHSS 4–7: 0 vs. 5.9%, p = 0.06; NIHSS 8+: 1.5 vs. 6.6%, p = 0.18) and by treatment with tPA and/or thrombectomy (Yes: 2.6 vs. 9.1%, p = 0.30; No: 0 vs. 2.9%, p = 0.25). DAPT was not associated with major bleeding in either the univariate or the multivariate regression.Conclusions: In this single center cohort, symptomatic ICH and the composite of serious systemic bleeding and symptomatic ICH was rare in patients on DAPT. Relative to single antiplatelet therapy DAPT was not associated with an increased risk of in-hospital bleeding in patients with moderate and severe ischemic stroke.