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ABSTRACT:Oral anticoagulation (OAC) prevents stroke in atrial fibrillation, yet a residual stroke risk remains. In this single-center retrospective analysis of acute ischemic stroke patients despite OAC, suboptimal OAC treatment is common (30%: inappropriate dosing (17%); patient non-adherence (13%)). Other causes of stroke included OAC interruption (14.5%), a competing stroke mechanism (11.0%), and undetermined breakthrough stroke in 44.5%. Overall, easily modifiable causes of ischemic stroke despite OAC are common. Accordingly, strategies to improve treatment compliance, including appropriate dosing along with guideline-based risk factor and periprocedural OAC management, should be emphasized to improve secondary stroke prevention in this patient population.

A 77-year-old right-handed functionally independent woman presented to the emergency department about 12 hours after the acute onset of speech difficulties. The patient was a nonsmoker and was receiving treatment [...]

Patients with pre-stroke disability, defined as a modified Rankin Scale (mRS) ≥3, were excluded from most trials of endovascular thrombectomy (EVT) for acute stroke. We sought to evaluate the prognostic factors associated with favorable outcome in stroke patients with known disability undergoing EVT, and the impact of successful reperfusion.

Intravenous thrombolysis with alteplase bolus followed by infusion is a global standard of care for patients with acute ischaemic stroke. We aimed to determine whether tenecteplase given as a single bolus might increase reperfusion compared with this standard of care.

ABSTRACT:Background:Stroke survivors may be at higher risk of incident cancer, although the magnitude and the period at risk remain unclear. We conducted a retrospective cohort study to compare the risk of cancer in stroke survivors to that of the general population.Methods:The Canadian Longitudinal Study on Aging is a large population-based cohort of individuals aged 45–85 years when recruited (2011–2015). We used data from the comprehensive subgroup (n = 30,097) to build a retrospective cohort with individual exact matching for age (1:4 ratio). We used Cox proportional hazards models to estimate hazard ratios of new cancer diagnosis with and without a prior stroke.Results:We respectively included 920 and 3,680 individuals in the stroke and non-stroke groups. We observed a higher incidence of cancer in the first year after stroke that declined afterward (p-value = 0.030). The hazard of new cancer diagnosis after stroke was significantly increased (hazard ratio: 2.36; 95% CI: 1.21, 4.61; p-value = 0.012) as compared to age-matched non-stroke participants after adjustments. The most frequent primary cancers in the first year after stroke were prostate (n = 8, 57.1%) and melanoma (n = 2, 14.3%).Conclusions:The hazard of new cancer diagnosis in the first year after an ischemic stroke is about 2.4 times higher as compared to age-matched individuals without stroke after adjustments. Surveillance bias may explain a portion of post-stroke cancer diagnoses although a selection bias of healthier participants likely led to an underestimation of post-stroke cancer risk. Prospective studies are needed to confirm the potentially pressing need to screen for post-stroke cancer.

ABSTRACT:This is an observational cohort study comparing 156 patients evaluated for acute stroke between March 30 and May 31, 2020 at a comprehensive stroke center with 138 patients evaluated during the corresponding time period in 2019. During the pandemic, the proportion of COVID-19 positive patients was low (3%), the time from symptom onset to hospital presentation was significantly longer, and a smaller proportion of patients underwent reperfusion therapy. Among patients directly evaluated at our institution, door-to-needle and door-to-recanalization metrics were significantly longer. Our findings support concerns that the current pandemic may have a negative impact on the management of acute stroke.

ABSTRACT:Introduction:The benefit of late window endovascular treatment (EVT) for anterior circulation ischemic stroke has been demonstrated using perfusion-based neuroimaging. We evaluated whether non-contrast CT (NCCT) and CT-angiogram (CTA) alone can select late-presenting patients for EVT.Methods:We performed a retrospective comparison of all patients undergoing EVT at a single comprehensive stroke center from January 2016 to April 2017. Patients planned for EVT were divided into early (<6 hours from onset) and late (≥6 hours from onset or last time seen normal) window groups. Incidence of symptomatic hemorrhagic transformations (sHTs) at 24 hours and 3-month modified Rankin scores (mRSs) were compared.Results:During the study period, 204 (82%) patients underwent EVT in the early and 44 (18%) in the late window. Median (interquartile range) NIH Stroke Scale Score was similar between groups (early: 18 [15–23] vs. late: 17 [13–21]), as were median ASPECT scores (early: 9 [8–10] vs. late: 9 [7–9]). In the late window, 42 (95%) strokes were of unknown onset. Similar proportions of sHT occurred at 24 hours (early: 12 [6%] vs. late: 4 [9%], p= 0.43). At 3 months, the proportion of patients achieving functional independence (mRS 0–2) were comparable in the early (80/192 [42%]) and late (16/41 [39%]) windows (p= 0.76).Conclusion:NCCT- and CTA-based patient selection led to similar functional independence outcomes and low proportions of sHT in the early and late windows. In centers without access to perfusion-based neuroimaging, this pragmatic approach could be safe, particularly for strokes of unknown onset.

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ABSTRACT:Introduction:Prehospital identification of large vessel occlusion (LVO) stroke may expedite treatment by direct transport to comprehensive stroke centers (CSCs) with endovascular capabilities. The Cincinnati Prehospital Stroke Scale (CPSS) is commonly used for prehospital stroke detection. We aimed to assess whether (1) a high CPSS score can identify LVO and (2) an Emergency Medical Service (EMS) redirection protocol based on high CPSS accelerated endovascular treatment (EVT).Methods:A retrospective comparison of patients transported by EMSs for suspected stroke to a high-volume CSC over a 16-month period, before and after implementation of an EMS redirection protocol based on high CPSS score (3/3). Charts were reviewed to determine the presence of LVO. Time to EVT and 3-month outcomes were compared before and after implementation.Results:A prehospital CPSS 3/3 score was found in 223 (59%) patients, demonstrating positive and negative predictive values for LVO of 29% and 94%, respectively. CPSS-based EMS redirection increased the proportion of EVT performed after direct transport to CSC [before: 21 (36%), after: 45 (63%), p< 0.01] and decreased median first door-to-groin puncture time by 28 minutes [109 (interquartile range (IQR) 64–116) versus 81 (IQR 56–130), p= 0.03]. At 3 months, the proportion of patients achieving functional independence (modified Rankin score 0–2) went from 20/57 (35%) to 29/68 (43%) (p= 0.39) following implementation.Conclusions:CPSS-based EMS redirection accelerated identification of LVO strokes in the out-of-hospital setting and decreased time to EVT. Nevertheless, this protocol was also associated with high rates of non-LVO stroke. Impact on clinical outcomes should be evaluated in a larger cohort.

Longitudinal evolution of intracranial hemorrhage by using quantitative susceptibility mapping demonstrated susceptibility differences in different disease stages, which are not found at conventional MRI.

Diffusion-weighted imaging (DWI) lesions have been identified both inside and outside the perihematoma region. We tested the hypotheses that larger hematoma volumes and blood pressure reduction are associated with DWI lesions.

The Intracerebral Hemorrhage Acutely Decreasing Arterial Pressure Trial (ICH ADAPT) demonstrated blood pressure (BP) reduction does not affect mean perihematoma or hemispheric cerebral blood flow. Nonetheless, portions of the perihematoma and borderzones may reach ischemic thresholds after BP reduction. We tested the hypothesis that BP reduction after intracerebral hemorrhage results in increased critically hypoperfused tissue volumes.

To determine the association between silent ischemic lesions (SILs) on baseline brain MRI and recurrent stroke in young adults with first-ever ischemic stroke.

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Introduction:Early anticoagulation after acute ischemic stroke is usually avoided due to the risk of hemorrhagic transformation (HT). We aimed to assess the rate of radiological HT associated with direct oral anticoagulant (DOAC) initiation within 48 hours vs. > 48 hours in the post-stroke period.Methods:A pooled analysis of five studies of DOAC initiation within 14 days of ischemic stroke onset was conducted. The primary endpoint was incident radiographic HT on follow-up imaging. Secondary endpoints included symptomatic HT, new parenchymal hemorrhage (PH1 or asymptomatic PH2), recurrent systemic events, systemic hemorrhagic complications, mortality within the study period, final modified Rankin Scale score. The results were reported as odds ratio (OR) with 95% confidence interval (CI).Results:A total of 468 patients were enrolled. Median infarct volume was 1.35 (0-7.5) ml, and National Institutes of Health Stroke Scale was 1 (0-3). Incident radiographic HT was seen on follow-up scan in 29 patients. DOAC initiation within 48 hours from index event onset was not associated with incident HT (adjusted OR 0.67, [0.31 - 1.50] P=0.34). No patients developed symptomatic HT. Conversely, 25 patients developed recurrent ischemic events, 64% of which occurred within 14 days. Initiating DOAC within 48 hours of onset was not associated with a reduction in the risk of recurrent ischemic events (OR 0.47, [0.19 - 1.20] P=0.12). In contrast to HT, recurrent ischemic events were associated with poor functional outcomes (OR=6.8, [2.95 - 15.63], p<0.0001).Conclusions:Early DOAC initiation after stroke was not associated with increased incident HT risk. Recurrent ischemic events were common and associated with poor outcomes. These data may be useful for estimating outcome rates and sample size calculations in future trials of early versus late DOAC initiation after AF-related stroke.

Introduction:Several comprehensive stroke centers (CSC) have reported increased delays to reperfusion in acute stroke during the COVID-19 pandemic, but it is unknown whether the pandemic is associated with worse functional outcomes in EVT-treated patients.Methods:We performed an observational cohort study of consecutive adult patients evaluated for suspected stroke at our CSC (located in Montreal, a Canadian pandemic epicenter) between March 30 and May 15 2020 (prospective pandemic cohort) and 2019 (retrospective non-pandemic cohort). We excluded in-hospital strokes. We compared short-term (in-house door-to-puncture and door-to-recanalization delays, TICI 2b/3, complications during EVT) and long-term (90-day mRS ≤2 and death) outcomes with univariate analyses. We assessed the effect of the pandemic on 90-day mRS while controlling for clinical confounders.Results:Overall, 111 and 106 patients were included in the pandemic and non-pandemic cohorts, respectively. The prevalence of COVID-19 in the pandemic cohort was 3% (3/104). Among ischemic stroke patients, 31/77 (40%) and 41/71 (58%) underwent EVT in each respective cohort (p=0.03). Among EVT-treated patients, baseline characteristics and NIHSS scores were similar (median [interquartile range]: 20 [12-25] vs 18 [14-20], p=0.18), but pre-stroke mRS was lower in the exposed cohort (0 [0-1] vs 1 [0-2], p=0.04). Door-to-puncture (87 [65-102] vs 56 [47-74] min, p=0.07) metrics were similar, but door-to-recanalization (122 [99-126] vs 89 [67-97] min, p<0.01) metrics were longer during the pandemic. The proportions of patients with TICI 2b/3 (94 vs 85%, p=0.27) and with complications during EVT (23 vs 22%, p=0.95) were similar, as were those for 90-day mRS ≤2 (42 vs 37%, p=0.64) and death (19 vs 20%, p=0.99). The logistic multivariate regression did not disclose an association between the COVID-19 pandemic and 90-day mRS ≤2 (aOR 0.70, 95% CI 0.06-7.95).Conclusion:The COVID-19 pandemic does not appear to have a negative impact on 90-day functional status among EVT-treated patients despite increased delays to recanalization. However, patient selection may have been stricter during the pandemic, as a smaller proportion of evaluated patients underwent EVT and those treated had lower pre-stroke mRS.

Background:Cancer promotes thromboembolism through inflammation and hypercoagulability, and an ischemic stroke may be the first sign of an occult malignancy. Stroke survivors may be at higher risk of incident cancer diagnosis, although the magnitude and the period at risk remain unclear. We conducted a retrospective cohort study to compare the risk of cancer in stroke survivors to that of the general population.Methods:The Canadian Longitudinal Study on Aging (CLSA) is a large, national population-based cohort of Canadian women and men aged 45-85 years when recruited between 2011 and 2015. Participants provided information on socio-demographics and prior diagnoses. We used data from the comprehensive sub-group (n=30,097) to build a retrospective cohort of participants with and without prior stroke by exact matching for age (1:4 ratio). We used log-binomial regression models to estimate the risk of cancer in people with versus without ischemic stroke while adjusting for shared risk factors.Results:We included 920 individuals in the stroke group and 3,680 individuals in the control group, respectively followed for a median of 10 (interquartile range [IQR]: 4, 17) and 11 years (IQR: 5, 19). Most inclusion events in the stroke group were minor strokes or transient ischemic attacks (n=614, 66.7%). We observed a higher incidence of cancer in the first year after stroke that declined thereafter (p=0.030). The risk of new cancer diagnosis after stroke was significantly increased (relative risk: 2.38; 95% confidence interval: 1.18, 4.63; p-value=0.012) after adjustments. The most frequent primary cancers in the first year after stroke were prostate (n=8, 57.1%) and melanoma (n=2, 14.3%).Conclusions:The risk of new cancer diagnosis in the first year after an ischemic stroke is about 2.4 times higher as compared to age-matched individuals from the general population without stroke after adjustments. Surveillance bias may explain a portion of post-stroke cancer diagnoses in the stroke group although a CLSA tendency to recruit healthier participants likely led to an underestimation of post-stroke cancer risk. Prospective experimental trials are needed to quantify the potentially pressing need to screen for post-stroke cancer.