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Background and Purpose: Intracerebral hemorrhage (ICH) accounts for around 10% of stroke, but carries 50% of stroke mortality. ICH characteristics and prognostic factors specific to the Stroke Belt are not well defined by race. Methods: Records of patients admitted to the University of Alabama Hospital with ICH from 2017 to 2019 were reviewed. We examined the association of demographics; clinical and radiographic features including stroke severity, hematoma volume, and ICH score; and transfer status with in-hospital mortality and discharge functional status for a biracial population including Black and White patients. Independent predictors of in-hospital mortality and functional outcome were examined using logistic regression. Results: Among the 275 ICH cases included in this biracial analysis, Black patients (n = 114) compared to White patients (n = 161) were younger (60.6 vs. 71.4 years, P < 0.0001), more often urban (81% vs. 64%, P < 0.01), more likely to have a history of hypertension (87% vs. 71%, P < 0.01), less often transferred (44% vs. 74%, P < 0.01), and had smaller median initial hematoma volumes (9.1 vs. 12.6 mL, P = 0.041). On multivariable analysis, Glasgow Coma Scale (GCS) for White patients (OR 13.0, P < 0.0001), hyperlipidemia for Black patients (OR 13.9, P = 0.019), and ICH volume for either race (Black patients: OR 1.05, P = 0.03 and White patients: OR 1.04, P < 0.01) were independent predictors of in-hospital mortality. Conclusions: Hypertension is more prevalent among Black ICH patients in the Stroke Belt. The addition of hyperlipidemia to the ICH score model improved the prediction of mortality for Black ICH patients. No differences in in-hospital mortality or poor functional outcome were observed by race.

Domain-specific endpoints are assessments that correspond to the output of individual neural systems and are useful for capturing treatment effects on specific behaviors. By contrast, global endpoints combine several attributes into a single score and are useful for capturing broad treatment effects in a summary way. While global endpoints have become the de facto mechanism required to define benefit in stroke trials, they also have important limitations, some of which might be addressed by simultaneously measuring domain-specific endpoints. Substantial opportunity remains to identify quantifiable patient benefit that would otherwise not be captured by global endpoints. Potential advantages of incorporating domain-specific endpoints in acute stroke trials are discussed, such as increased granularity of measurement, improved understanding of how therapies affect the brain between acute treatment and day 90, and optimized therapeutic translation. Potential disadvantages are also considered, including time and cost of administering domain-specific endpoints, as well as statistical implications. Domain-specific endpoints and global endpoints are not mutually exclusive, and both capture clinical benefits to patients. Incorporating a broader set of outcome assessments in stroke trials, including both global and domain-specific endpoints, is warranted.

Background and PurposeAcute ischemic stroke caused by large vessel occlusions (LVO) is a major contributor to stroke deaths and disabilities; however, identification for emergency treatment is challenging.AimsTo evaluate the diagnostic accuracy of a panel of biomarkers for LVO prediction.Methods170 patients with suspected stroke were recruited retrospectively at one hospital. We analysed the plasma levels of D-dimer, OPN, OPG, GFAP, vWF, and ADAMTS13 in LVO vs non-LVO. Diagnostic performance was estimated by using blood biomarkers alone or in combination with NIHSS-derived stroke severity scales.ResultsOur patient cohort comprised 20% stroke mimics, 11% transient ischemic attack, 11% hemorrhagic stroke, 15% LVO ischemic stroke, 28% non-LVO ischemic stroke, and 15% ischemic stroke with unknown LVO status. Multivariable analysis found that the optimal set of blood biomarkers for LVO prediction was D-dimer (OR 15.4, 95% CI 4.9 to 57.6; p-valueConclusionsThe combination of D-dimer, GFAP, and stroke scales could provide a simple and highly accurate tool for identifying LVO patients.

Introduction: The Emergency Medical Stroke Assessment (EMSA) is a six point stroke severity scale with one point each for gaze preference, facial droop, arm drift, leg drift, abnormal naming, and abnormal repetition that was developed to help emergency medical services (EMS) providers identify acute ischemic stroke (AIS) patients with large vessel occlusion (LVO). We hypothesized that the EMSA would detect left hemisphere LVO with a higher sensitivity than right hemisphere LVO. Methods: We trained 24 trauma system-based emergency communication center (ECC) paramedics in the EMSA. ECC-guided EMS in performance of the EMSA on patients with suspected stroke. We compared the sensitivity, specificity, area under the curve (AUC), and 95% confidence interval (CI) of ECC-guided prehospital EMSA for right versus left hemisphere ICA or M1 occlusion. Results: We enrolled 569 patients from September 2016 through February 2018, out of which 236 had a discharge diagnosis of stroke and 173 had a diagnosis of AIS. We excluded patients with bilateral (n=21) and brainstem (n=21) AIS. There were 64 patients with left hemisphere AIS including 19 with LVO. There were 67 patients with right hemisphere AIS including 22 with LVO. A score of ≥ 4 points yielded a sensitivity of 84.2 (95% CI = 60.4-96.6) and specificity of 66.7 (51.1-80.0) for left hemisphere LVO compared to a sensitivity of 68.2 (45.1-86.1) and specificity of 73.9 (58.9-85.7) for right hemisphere LVO. For predicting a left hemisphere LVO, the AUC was 0.77 (0.65-0.90) compared to 0.66 (0.50-0.82) for right-sided LVO. Assigning 2 points for abnormal gaze yielded an AUC of 0.78 (0.66-0.91) versus 0.67 (0.52-0.83) for left and right hemisphere LVO, respectively. Conclusions: The EMSA, like the National Institutes of Health Stroke Scale (NIHSS) upon which it is based, is more sensitive to left compared to right hemisphere LVO. More heavily weighting abnormal gaze did not improve the sensitivity of the EMSA for right hemisphere LVO. There is no comparable data on the right versus left hemisphere performance of other prehospital scales. There is a need to develop sensitive tests of right hemisphere dysfunction that are suitable for use in the field.

Objective: To determine if aortic stenosis (AS) is associated with altered cerebral hemodynamics and impaired neurocognition, and whether TAVR improves hemodynamics and cognition. Background: AS results in higher systolic pressure to overcome resistance from the stenotic valve, leading to heart failure and decline in cardiac output. There has been no baseline assessment of CBF with neurocognition in AS, or the effects of valve replacement. Methods: In 40 patients with planned TAVR, transcranial Doppler (TCD) assessed bilateral MCA mean flow velocity (MFV); abnormality was < 30cc/sec. The neurocognitive battery assessed memory, language, attention, visual-spatial skills, and executive function, yielding an average Z-score. Impairment was < 1.5 SD’s below the normative mean. Results: The mean age was 78 years, 59% male, and the mean valve gradient was 46.87%. Mean follow-up was 36 days post-TAVR (range 27 - 55). Before TAVR, the average MFV was 42 cc/sec (SD=10.22), and the mean cognitive score was -0.22 SD’s (range -1.99 to 1.08) below the normative mean. Of the 5 with abnormal MFV’s, none had abnormal cognition (average=0.19 SD’s above the normative mean). After TAVR, the MFV was 43 cc/sec, not different from baseline (p=0.56). The post-TAVR average Z-score was 0.01 SD’s above the normative mean, also not different from baseline (p=0.29). There was no correlation between the change scores in MFV and in neurocognition (r = 0.08, p= 0.69). Conclusions: Among patients with severe AS, there was no correlation at baseline between abnormal MFV’s on TCD and abnormal neurocognition. It was therefore unsurprising that there was little impact of valve replacement on these measures of cerebral blood flow and brain function. Prior assumptions about diminished CBF and the relationship to cognitive function may not be supported.

Background: The NorthEast Cerebrovascular Consortium (NECC) was established in 2006 to improve stroke-systems-of-care models. Methods: This study evaluates the increase in stroke quality over time in NECC and Non-NECC regions, defined as the change in proportion of hospitals over time who received State or National Primary/Comprehensive Stroke Center (PSC/CSC) certification, participated in a national quality program (Get-With-The-Guidelines-Stroke (GWTG-S)), or received GWTG-S Performance Achievement Awards (PAA) from 2005-2013. Analysis of trends was performed (Cochran-Armitage/Cochran-Mantel-Haenszel tests; Generalized-Estimating Equations). As an exploratory analysis eight NECC region Departments of Health (DOH) were surveyed regarding perceptions of the NECC. Results: During the study period, there were 433.1 ± 10.2 vs 3986.4 ± 187.7 hospitals per year in the NECC vs non-NECC regions. Rate of growth per year increased in both groups for each measure but to a greater degree in the NECC vs Non-NECC regions: PSC/CSC (5.4%/yr vs 3.2%/yr), GWTG-S participation (5.0%/yr vs 2.9%/yr), and PAAs (5.2%/yr vs 2.1%/yr), with state-based certification growth also being higher in the NECC region (4.2%/yr vs 0.4%/yr; all comparisons p < 0.0001). After adjusting for year, significantly more NECC hospitals had PSC/CSC certification, GWTG-S participation, and GWTG-S PAAs than non-NECC sites (all analyses p < 0.0001). One hundred percent of NECC region DOHs were aware of the NECC and involved in functions, 87.5% indicated the NECC provided beneficial assistance. Conclusions: There has been a higher rate of growth of state certification contrasted to national PSC/CSC certification, and a higher rate of growth of participation and achievement in GWTG-S in the northeast region compared to other US regions.

Acute ischemic stroke caused by large vessel occlusions (LVOs) is a major contributor to stroke deaths and disabilities, however, identification for emergency treatment is challenging. We recruited two separate cohorts of suspected stroke patients and screened a panel of blood-derived protein biomarkers for LVO detection. Diagnostic performance was estimated by using blood biomarkers in combination with NIHSS-derived stroke severity scales. Multivariable analysis demonstrated that D-dimer (OR 16, 95% CI 5–60, p-value &lt, 0.001) and GFAP (OR 0.002, 95% CI 0–0.68, 0.05) comprised the optimal panel for LVO detection. Combinations of D-dimer and GFAP with a number of stroke severity scales increased the number of true positives, while reducing false positives due to hemorrhage, as compared to stroke scales alone (p-value &lt, 0.001). A combination of the biomarkers with FAST-ED resulted in the highest accuracy at 95% (95% CI: 87–99%), with sensitivity of 91% (95% CI: 72–99%), and specificity of 96% (95% CI: 90–99%). Diagnostic accuracy was confirmed in an independent cohort, in which accuracy was again shown to be 95% (95% CI: 87–99%), with a sensitivity of 82% (95% CI: 57–96%), and specificity of 98% (95% CI: 92–100%). Accordingly, the combination of D-dimer and GFAP with stroke scales may provide a simple and highly accurate tool for identifying LVO patients, with a potential impact on time to treatment.

Background Delirium after acute stroke is a serious complication. Numerous studies support a benefit of multicomponent interventions in minimizing delirium-related complications in at-risk patients, but this has not been reported in acute stroke patients. The purpose of this study was to explore the feasibility of conducting a randomized (delirium care) versus usual standardized stroke care (usual care) in reducing delirium in acute stroke. Objective This pilot study assessed the feasibility of (1) enrollment within the 48-hour window when delirium risk is greatest, (2) measuring cognitive function using the Montreal Cognitive Assessment, (3) delivering interventions 7 days per week, and (4) determining delirium incidence in stroke-related cognitive dysfunction. Methods A 2-group randomized controlled trial was conducted. Patients admitted with ischemic and hemorrhagic strokes and 50 years or older, English speaking, and without delirium on admit were recruited, consented, and randomized to usual care or delirium care groups. Results Data from 125 subjects (delirium care, n = 59; usual care, n = 66) were analyzed. All Montreal Cognitive Assessment subscales were completed by 86% of subjects (delirium care, mean [SD], 18.14 [6.03]; usual care, mean [SD], 17.61 [6.29]). Subjects in the delirium care group received a mean of 6.10 therapeutic activities (range, 2-23) and daily medication review by a clinical pharmacist using anticholinergic drug calculations. Delirium incidence was 8% (10/125), 3 in the delirium care group and 7 in the usual care group. Conclusion Findings support the feasibility of delivering a multicomponent delirium prevention intervention in acute stroke and warrants testing intervention effects on delirium outcomes and anticholinergic medication administration.

Objective: Improve prehospital identification of acute ischemic stroke patients with large vessel occlusion (LVO) by using a trauma system-based emergency communication center (ECC) to guide the emergency medical service (EMS). Methods: We trained 24 ECC paramedics in the Emergency Medical Stroke Assessment (EMSA). ECC-guided EMS in performance of the EMSA on patients with suspected stroke. During the second half of the study, we provided focused feedback to ECC after reviewing recorded ECC-EMS interactions. We compared the sensitivity, specificity, and area under the receiver operator characteristics curve (AUC) and 95% confidence interval of ECC-guided EMSA to the NIH Stroke Scale (NIHSS) for predicting a discharge diagnosis of LVO. Results: We enrolled 569 patients from September 2016 through February 2018. Of 463 patients analyzed, 236 (51%) had a discharge diagnosis of stroke and 227 (49%) had a nonstroke diagnosis. There were 45 (19%) stroke patients with LVO. For predicting LVO, there was no significant difference between the EMSA AUC = .68 (.59-.77) and the NIHSS AUC = .73 (.65-.81). An EMSA score greater than or equal to 4 had sensitivity = 75.6 (60.5-87.1) and specificity = 62.4 (57.6-67.1) for LVO. During the first 9 months of the study, the EMSA AUC = .61 (.44-.77) compared to an AUC = .74 (.64-.84) during the second 9 months. Conclusions: ECC-guided prehospital EMSA is feasible, has similar ability to predict LVO compared to the NIHSS, and has sustained performance over time.

Introduction: The role of intravenous recombinant tissue plasminogen activator (IV r-tPA) prior to endovascular therapy (ET) in acute ischemic stroke (AIS) has been heavily debated in recent literature. Understanding the direct relationship of IV r-tPA to occlusive thrombus size and migration may lead to further understanding of the potential benefits of IV r-tPA in AIS cases treated with ET. Methods: We retrospectively studied consecutive AIS patients who underwent a CT angiogram (CTA) followed by ET at our center from 7/2016-1/2017. We compared demographic, clinical, and imaging characteristics between subjects treated with or without IV r-tPA. Three raters, blind to IV r-tPA exposure, independently evaluated clot burden and location of each thrombus on CTA in comparison to digital subtraction angiography (DSA) images. Results: Among 29 patients meeting inclusion/exclusion criteria, 16 received IV r-tPA prior to ET and 13 received ET alone. Agreement among raters ranged from 0.296 (clot burden score of thrombus on DSA) to 0.800 (location of thrombus on CTA). There were no statistically significant differences in the treated and untreated groups (Table). The odds of distal migration of clot or recanalization on subsequent DSA among tPA treated patients was more than 4 times that of non-tPA treated patients (OR 4.28, 95% CI 0.71, 25.92). Conclusion: In summary, 43.8% of patients in the IV r-tPA plus ET treated group exhibited distal migration of a thrombus or recanalization when observed on DSA, compared to 15.4% in the ET-only group. Although our results suggest that IV r-tPA may change the size and location of the thrombus, our results were not adequately powered to detect significant differences. However, the inter-rater reliability was favorable, suggesting that this investigational technique may be successfully applied to a larger sample size in future studies investigating the role of IV r-tPA bridging therapy in AIS treated with ET.

Introduction: We are prospectively validating a model of communication center guided prehospital identification of stroke patients with large vessel occlusion (LVO). Goal: Assess the inter-rater agreement between a Vascular Neurologist and Alabama Trauma Communication Center (ATCC) personnel in diagnostic classification of stroke patients. Methods: The ATCC is staffed by paramedic-trained dispatchers who field calls from Emergency Medical Service (EMS) responders and maintain up-to-the-minute status of hospitals and resources 24/7. We trained ATCC personnel in stroke pathology, pathophysiology, appropriate patient selection for thrombolytic and endovascular therapies; and the previously derived 6 point Emergency Medical Stroke Assessment (EMSA). ATCC personnel guided EMS responders in the Birmingham Regional Emergency Medical Services System (BREMSS), and paged-out a hospital stroke prenotification that included specific EMSA scale items (gaze, facial droop, arm drift, leg drift, naming, and repetition). All interactions between the ATCC and EMS responders were recorded, allowing review of audio files and ongoing quality improvement. ATCC personnel and a vascular neurologist separately reviewed recordings and assigned scores to each patient according to the deficit stated by the EMS. To determine inter-rater reliability we utilized the Kappa statistic with a significance level of 0.05, and 95% confidence intervals (CI). Results: We sampled a total of 146 patients. We observed statistically significant agreement between the raters for all EMSA components, with 71% (CI=45-97%, p Conclusion: We conclude that there is moderate to substantial agreement in most stroke assessment items by a paramedic staffed communication center and a vascular neurologist. There was only fair inter-rater agreement for repetition. Paramedic-trained dispatchers can reliably guide EMS responders and score the Emergency Medical Stroke Assessment.

Background: The stroke belt has a higher stroke mortality rate compared to other regions of the United States with Alabama recording about 3,000 deaths yearly. The University of Alabama at Birmingham (UAB) is the only comprehensive stroke center (CSC) in Alabama equipped to manage the most complex stroke patients. Objective: The purpose of this study was to determine the characteristics and prognosis of patients transferred to a comprehensive stroke center in the stroke belt. Methods: Data was abstracted from the electronic health records of patients admitted to the stroke service between 2016 and 2018. We assessed differences between transfer and non-transfer patients in terms of demographics, stroke severity, insurance, administration of alteplase (t-PA) and thrombectomy (IA). We also evaluated the relationship between the Alabama state stroke designation of the originating hospital including non-stroke centers (level 0), acute stroke ready hospitals, ASRH (level 3), primary stroke centers, PSC (level 2) and direct admissions to UAB (level 1) and characteristics and prognosis of patients. Results: 1107 patients were assessed for the study with 402(36%) being transfers. Race, NIHSS,TPA and IA use, discharge disposition were associated with the level of stroke center, as shown in the table. Level 2 centers transferred patients with more severe strokes, and a higher proportion of TPA and IA use. Non-transfer patients had the best outcome with Home as their primary discharge location compared to patients transferred from level 2 stroke centers. Conclusion: About 36% of our stroke discharge volume is a result of patients transferred to UAB from outside hospitals. We conclude that Level 2 stroke centers are appropriately transferring patients with more severe stroke to CSCs compared to transfers from non-stroke centers and acute stroke ready hospitals. Some of the patients transferred to a CSC from non-stroke centers and ASRHs could be managed at PSCs.

Introduction: There is need for sustainable models of effective prehospital stroke triage. Goal: Prospectively validate communication center guided prehospital identification of stroke patients with large vessel occlusion (LVO). Methods: We trained Alabama Trauma Communication Center (ATCC) paramedics in the previously derived 6 point Emergency Medical Stroke Assessment (EMSA). ATCC staff guided Emergency Medical Service (EMS) responders in the Birmingham Regional Emergency Medical Services System (BREMSS), and paged-out a hospital prenotification that included specific EMSA items (gaze, facial droop, arm drift, leg drift, naming, and repetition). Ongoing quality improvement was designed to enable the ATCC staff to effectively guide EMS responders. We derived the sensitivity, specificity, negative likelihood ratio (LR-), positive likelihood ratio (LR+), and receiver operator characteristics area under the curve (AUC) and 95% confidence intervals (CI) of ATCC guided EMSA for predicting a discharge diagnosis of LVO for patients transported to the University of Alabama at Birmingham. Results: We enrolled 521 patients from September 2016 through February 2018. Patients who only responded to pain (n=29, 5.6%) or who were unresponsive (n=21, 4%) were excluded. Of 471 patients analyzed, 247(52%) had a discharge diagnosis of stroke, including 182 (74%) acute ischemic stroke, 36 (14%) intracerebral hemorrhage, and 29 (11%) transient ischemic attack. There were 45 (18%) stroke patients with proximal LVO, including 31 middle cerebral artery stem, 12 internal carotid artery, and 2 basilar artery. Overall, an EMSA score ≥ 4 had sensitivity = 75.6%, specificity = 62.2%, LR- = 0.39, and LR+ = 2.00 for proximal LVO. During the first 9 months of the study, the EMSA AUC = 0.61 (CI = 0.45 – 0.77) compared to an AUC = 0.74 (CI = 0.64 – 0.84) during the second 9 month period of the study. Conclusions: EMS stroke medical control based on communication center guided prehospital stroke assessment and ongoing quality improvement is feasible and results in sustained ability to identify patients with LVO. Further studies are needed to evaluate the impact of guided prehospital triage of patients with suspected LVO on health outcomes.

United States (US) and worldwide telestroke programs frequently focus only on emergency room hyper-acute stroke management. This article describes a comprehensive, telemedicine-enabled, stroke care delivery system that combines “drip and ship” and “drip and keep” models with a comprehensive stroke center primary hub at Ochsner Medical Center in New Orleans, advanced stroke-capable regional hubs, and geographically-aligned, “stroke-ready” spokes. The primary hub provides vascular neurology expertise via telemedicine and monitors care for patients remaining at regional hubs and spokes using a multidisciplinary team approach. By 2014, primary hub telestroke consults grew to ≈1000/year with 16 min average door to consult initiation and 20 min to completion, and 29% of ischemic stroke patients received recombinant tissue-type plasminogen activator (rtPA), increasing 275%. Most patients remained in hospitals close to home, but neurointensive care and interventional procedures were common reasons for primary hub transfer. Given the time sensitivity and expert consultation needed for complex acute stroke care delivery paradigms, telestroke programs are effective for fulfilling unmet care needs. Combining drip and ship and drip and keep management allows more patients to stay “local,” limiting primary hub transfer unless more advanced services are required. Post admission telestroke management at spokes increases personnel efficiency and can positively impact stroke outcomes.

Introduction: Given the rapid expansion of telestroke systems, an increasing number of patients with acute stroke-like presentations are receiving tele-evaluation for guidance of diagnostic and therapeutic decisions. There is limited data, however, regarding the accuracy of telestroke diagnosis. We examined the accuracy of telestroke diagnosis and evaluated predictors of misdiagnosis. Methods: We conducted a retrospective study of all telestroke consultations at our center between April 2015 and April 2016. Consultations were classified into one of 3 diagnostic categories: stroke/TIA, mimic, and uncertain. Telestroke diagnosis was compared with final diagnosis determined after review of additional emergency department testing or hospital admission. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for diagnosis of stroke/TIA vs mimic were calculated. Area under receiver-operating characteristic curve (AUC) analysis to predict true stroke was performed. Bivariate analysis based on the diagnostic categories examined association with sex, age, NIH Stroke Scale (NIHSS), stroke risk factors (CAD, DM, HLD, HTN, history of stroke/TIA, smoking), TPA given, bleeding after TPA, symptom onset to last known normal, symptom onset to consult, time of day of consult by 6 hour epoch, and consult duration. Logistic regression (LR) was performed as indicated by bivariate analysis. Results: 874 telestroke evaluations were included in our analysis. Sensitivity, specificity, PPV, NPV were 97.8%, 82.5%, 93.7% and 93.4%, respectively. AUC (95% CI) was 0.9061 (0.8749-0.9283). LR revealed OR (95% CI) of misdiagnosis for female gender of 1.9 (1.3-2.9). Conclusions: Our telestroke system is highly accurate in discriminating between stroke/TIA and stroke mimics with a tendency towards overdiagnosis of stroke. Female gender was associated with misdiagnosis.

Introduction: The widely used Cincinnati Prehospital Stroke Scale (CPSS) has a sensitivity for stroke identification of only about 50%. A previous study suggested that stroke was missed more frequently by EMS using the CPSS in patients without motor signs. The purpose of this study was to compare the elements of the CPSS to the corresponding items of the gold standard National Institutes of Health Stroke Scale (NIHSS). Hypothesis: Speech and language components of the NIHSS are more sensitive than the corresponding speech component of the CPSS. Methods: We retrospectively studied patients transported to University of Alabama at Birmingham by EMS with suspected stroke from January to May of 2016. We excluded patients who did not have the CPSS performed by EMS in the field or admission NIHSS performed by neurology residents and those without a discharge diagnosis of stroke. We compared the sensitivity of abnormal facial droop, arm drift, and speech of the CPSS to the corresponding NIHSS items (facial palsy ≥ 1, left or right motor arm ≥ 1, best language or dysarthria ≥ 1) for a discharge diagnosis of stroke by vascular neurologists. Results: There were 232 subjects (White, 52%; Black, 44%; men, 51%: age=66, sd=16) There was no difference in the sensitivity of arm drift for discharge diagnosis of stroke between the CPSS (77.6%, 95% CI 70-85) and NIHSS (79.2%, 71-87), p=0.13. Compared to the NIHSS, the CPSS had significantly lower sensitivities on tests of facial weakness (51.2%, 42-60 vs. 65.3%, 55-75, p=0.006) and speech and language abnormalities (63.2%, 54-72 vs.71.6%, 61-80, p Conclusions: CPSS items testing facial weakness and speech/language are significantly less sensitive compared to corresponding NIHSS items. This may relate to more rigorous testing of these items on the NIHSS, but may also relate to different examiners or settings. Prehospital scales derived from NIHSS items may not accurately reflect performance in the prehospital setting.

Introduction: Despite the fact that illicit substance use has been associated with intracerebral hemorrhage (ICH), it is not standard care to perform a urine drug screen (UDS) on all patients presenting with stroke symptoms. We examined predictors of performing a UDS in ICH patients and possible predictors of a positive UDS of those screened. Methods: We conducted a retrospective analysis of 180 patients diagnosed with ICH between September 2014 and November 2015. We compared demographics, clinical features including reported substance abuse and discharge disposition in the patients who received toxicology screening against those who did not. Logistic regression was performed to assess predictive factors for toxicology screening and the likelihood of a positive toxicology. Results: We identified 180 ICH patients of whom 123 received toxicology screening on arrival. There was no significant difference in sex, age, or race between the groups. A UDS was less likely to be performed if the patient transferred from an outside institution (48% vs 68%, p=0.01). Direct presenters had higher odds of getting a UDS compared to transfer patients, (OR: 2.4, 95% CI 1.2-4.9, p=0.01). Of those screened, 38% had a positive UDS. Race and sex were not significant predictors of toxicology results while age< 65 had higher odds of a positive toxicology compared to older patients (OR:4.5, 95% CI: 1.85-10.86, p=0.0009). Although most neuroimaging parameters of the ICH did not differ based on UDS, those with hydrocephalus had greater odds of having a positive UDS (OR 3.0, 95% CI 1.3-6.8, p=0.007) Conclusion: In our sample, we found that only two-thirds of patients received a UDS. Although transferred patients were less likely to receive screening, we did not identify other significant predictors of physician UDS ordering behavior. We found a high rate of positive UDS, particularly among younger patients, suggesting that routine drug screening should be performed in all patients with ICH.

Background/Purpose: The ICH score (ICHS) is commonly used to predict 30-day mortality in spontaneous ICH. Several investigators have evaluated additional factors in an attempt to refine this score, though none of these modifications have been incorporated into routine practice. We sought to determine whether incorporating additional radiographic features, specifically herniation and/or the degree of midline shift (MLS), improved the performance of the ICH score. Methods: We retrospectively reviewed 180 consecutive ICH patients admitted to a single comprehensive stroke center between September 2014 and November 2015. The outcome of interest was poor prognosis, defined as mRS of 4-6, at time of discharge. Admission head CTs were evaluated by a vascular neurologist to determine whether uncal, tonsillar or subfalcine herniation were present, and to quantify the degree of midline shift. Midline shift was treated as a categorical variable determined by measuring the shift of the septum pellucidum from midline at the level of the basal ganglia. Results: Patients with radiographic herniation present on admission had a much higher odds of poor outcome; however, this measure was specific (98%) but not sensitive (23%). Degree of midline shift performed similarly, with a specificity of 86% and a sensitivity of 36%. In our population, the ICH score was a better predictor of poor outcome than any of the combinations shown in the Table. For each unit increase in ICH score, the odds of a poor outcome increased by a factor of 2.6. Conclusion: Although clinicians often view radiographic evidence of herniation and midline shift as indicators of dire prognosis, incorporation of these features into a modification of the ICH score failed to improve upon the original scale.

Background This study aims to develop a simple scale to identify patients with prehospital stroke with large vessel occlusion (LVO), without losing sensitivity for other stroke types. Methods The Emergency Medical Stroke Assessment (EMSA) was derived from the National Institutes of Health Stroke Scale (NIHSS) items and validated for prediction of LVO in a separate cohort. We compared the EMSA with the 3-item stroke scale (3I-SS), Cincinnati Prehospital Stroke Severity Scale (C-STAT), Rapid Arterial oCclusion Evaluation (RACE) scale, and Field Assessment Stroke Triage for Emergency Destination (FAST-ED) for prediction of LVO and stroke. We surveyed paramedics to assess ease of use and interpretation of scales. Results The combination of gaze preference, facial asymmetry, asymmetrical arm and leg drift, and abnormal speech or language yielded the EMSA. An EMSA less than 3, 75% sensitivity, and 50% specificity significantly reduced the likelihood of LVO (LR− = .489, 95% confidence interval .366-0.637) versus 3I-SS less than 4 (.866, .798-0.926). A normal EMSA, 93% sensitivity, and 47% specificity significantly reduced the likelihood of stroke (LR− = .142, .068-0.299) versus 3I-SS (.476, .330-0.688) and C-STAT (.858, .717-1.028). EMSA was rated easy to perform by 72% (13 of 18) of paramedics versus 67% (12 of 18) for FAST-ED and 6% (1 of 18) for RACE (χ2 = 27.25, P Conclusions The EMSA has superior abilities to identify LVO versus 3I-SS and stroke versus 3I-SS and C-STAT. The EMSA has similar ability to triage patients with stroke compared with the FAST-ED and RACE, but is simpler to perform and interpret.

Background: There is an urgent need to rapidly identify patients with acute ischemic stroke due to large vessel occlusion (LVO) to improve access to endovascular therapy. Aim: To derive a scale to improve pre-hospital detection of LVO. Methods: A retrospective review of consecutive patents enrolled in our prospective Comprehensive Stroke Center registry from 2008-2013 was conducted. Patients were excluded if they were < 18 yrs, not ambulatory, or did not have MRA or CTA. Demographic and clinical characteristics were compared between patients with and without LVO, defined as occlusion of the intracranial internal carotid artery, basilar artery, or middle cerebral artery. We compared a novel Large Vessel Occlusion Scale (LVOS) to the Cincinnati Prehospital Stroke Severity Scale (CPSSS) by constructing ROC curves and determining their area under the curve (AUC). Results: A total of 1,663 patients were identified (mean age = 62 yrs, SD = 14, 45.6% women and 66.8% Black). LVO was present in 171 patients (10.3%). The LVOS is a 6 point scale derived from the NIHSS that includes 2 points for abnormal speech or language (NIHSS ≥ 1 for either), 1 point for gaze preference (NIHSS ≥ 1), 1 point for facial asymmetry (NIHSS ≥ 1), 1 point for asymmetrical arm drift (RUE ≠ LUE), and 1 point for asymmetrical leg drift (RLE≠LLE). The LVOS had an AUC of 0.688 (95% CI 0.736 - 0.640), compared to 0.646 (95% CI 0.693 - 0.598) for the CPSSS and 0.678 (95% CI 0.0.723 - 0.633) for the NIHSS. A LVOS score ≥ 3 was 75.4% sensitive (95% CI 68.5 - 81.4) and 50.3% specific, positive likelihood ratio of 1.517 and negative likelihood ratio of 0.162 in predicting LVO. A CPSSS score ≥ 2 was 46.8% sensitive (95% CI 39.7 - 54.0) and 90.0% specific, positive likelihood ratio of 2.870 and negative likelihood ratio of 0.238 in predicting LVO. Conclusions: The LVOS compares favorably to the CPSSS in its ability to identify patients with LVO. Prospective prehospital validation is needed.

Background and purpose: Occasionally, seizures can be an early complication of ischemic stroke. Recent studies have shown that hemorrhagic transformation is a predictive factor for early seizures as a complication of AIS (acute ischemic stroke). Our research looked as early seizures as a complication of AIS (either seizures on presentation in the emergency department or seizures while admitted for acute stroke), correlation with hemorrhagic transformation (HT), and the implication with poor functional discharge outcomes. Methods: We evaluated consecutive AIS patients from March 2014-April 2015 admitted to our comprehensive stroke center. The primary endpoint was the modified rankin scale (mRS) on discharge (“poor outcome” defined as a score of 3-6), and association with hemorrhagic transformation (defined as hemorrhagic transformation seen on repeat imaging - either CT or MRI). Seizures were defined as clinical seizures - we did not require EEG data for diagnosis of seizure. Results: A total of 773 patients met inclusion criteria with a mean age 64, 49.3% female, and 36.6% black. Of these patients, 29 (3.7%) presented with seizures at onset or as an early complication of stroke while in the hospital. In our population, 15.5% of all AIS patients had HT, and 47.5% of all AIS patients had poor functional outcomes. In our patient population, seizures were not an independent risk factor for HT as a complication of AIS (after adjusting for SBP on presentation, age and NIHSS, OR 0.64, 95% CI: 0.18-2.28, P 0.493). We found that early seizures as a complication of AIS was an independent risk factor for poor functional outcome on discharge (after adjusting for SBP on presentation, age and NIHSS, OR 13.3, 95% CI 2.69-65.9, P 0.0015). Conclusion: In our patient population, we did not find that seizure was an independent risk factor for HT as a complication for AIS. We did find that early seizures as a complication of AIS was an independent risk factor for poor functional outcome.

Background: Guidelines recommend acute ischemic stroke (AIS) patients be transported rapidly to the closest certified stroke center (SC). The impact of SC care on transfer patients who do not receive acute revascularization therapy is not well understood. We sought to compare patient characteristics, adverse events (AEs), and short term functional outcomes in patients directly presenting to and transferred into a comprehensive stroke center (CSC). Methods: We conducted a retrospective review of consecutive AIS patients transferred to our CSC from March 2014-April 2015. We excluded patients who received tPA or endovascular therapy. Demographic and clinical data were collected. We compared AEs (hemorrhagic transformation [HT], DVT, PE, urinary tract infection [UTI], pneumonia [PNA], bacteremia) and poor short term functional outcome, as defined by modified Rankin scale (mRS) score 3-6, among patients directly admitted to our CSC and patients transferred to our CSC. Results: Of 589 patients who did not receive revascularization therapy, 24.4% were transfers. Transfers were disproportionately white (76.4 vs 57.8%, p Conclusion: Despite having more severe strokes and higher frequency of adverse events, patients transferred into our CSC for a higher level of care did not have worse short term functional outcomes. This highlights the importance of specialized inpatient care provided in NICUs and stroke units by experienced multidisciplinary teams.

Introduction: The HIAT2 (Houston Intra Arterial Therapy-2) score has been used to predict poor functional outcome in acute ischemic stroke (AIS) patients undergoing endovascular therapy (ET). Little is known about HIAT2’s ability to predict other outcomes in non-ET samples. Aim: To test the ability of HIAT2 to predict poor functional outcome (mRS 4-6), in-hospital mortality, and inpatient palliative care (PC) consult in (1) ET, (2) IV tPA, and (3) untreated patients. Methods: A retrospective review of consecutive AIS patients presenting to our comprehensive stroke center (CSC) from March 2014 to April 2015. Demographic and clinical data were collected. HIAT2 was calculated as follows: age (≤59=0, 60-79=2, ≥80=4), glucose ( Results: Among the 776 AIS patients admitted to our CSC, 6.6% received acute ET, 14.6% received IV tPA, and 79.8% received neither. For ET patients HIAT2 had an AUC of 0.592 for mRS 4-6, AUC 0.569 for PC, and AUC 0.656 for death. For tPA patients HIAT2 had an AUC of 0.686 for mRS 4-6, AUC 0.798 for PC, and AUC 0.825 for death. For untreated patients HIAT2 had an AUC of 0.629 for mRS 4-6, AUC 0.649 for PC, and AUC 0.641 for death. In the tPA treated sample, a HIAT2 score ≥4 had a sensitivity and specificity of 0.436 and 0.819 in predicting mRS 4-6, sensitivity and specificity of 0.667 and 0.782 for PC, and sensitivity and specificity of 0.733 and 0.806 for death. Discussion: Our results suggest that the variables used to create the HIAT2 score are useful in predicting poor outcomes in untreated, tPA treated, and ET patients. Despite its ability to predict poor outcome in these samples, treatment should not be withheld from patients that otherwise qualify.

Background: Few large studies exist on volume depletion and its association with outcomes in acute ischemic stroke (AIS) patients. A common marker of volume status is the calculated blood urea nitrogen (BUN) to serum creatinine (SCr) ratio. We examined the association between admission volume depletion (BUN/SCr > 15) and discharge outcome in AIS patients. Methods: Consecutive patients (March 2014 - April 2015) who presented with AIS to our Comprehensive Stroke Center (CSC) were retrospectively analyzed. Demographics, medical history, imaging, initial lab values, stroke severity (NIHSS), and discharge disposition were recorded. Patients with BUN/SCr 15 were compared and good outcome defined as discharge home. We performed logistic regression adjusting for admission NIHSS and age. Results: We identified 776 patients who met inclusion criteria. Patients with BUN/SCr >15, were older (median 61 vs. 68, p15 was associated with lower odds of good outcome at discharge (OR=0.57, 0.42 - 0.78; p< 0.001), this relationship persisted after adjusting for known predictors (OR=0.70, 0.49 -1.00; p=0.055). Conclusions: After controlling for age and NIHSS, volume depletion in AIS patients estimated by BUN/SCr ratio was associated with poor discharge outcome, complicated hospital course, increased LOS, and in-hospital mortality. This simple ratio can be used in the early evaluation and treatment of AIS. However, multi-center prospective studies are needed to determine if volume correction is confounding this association.

Introduction: Nearly 40% of stroke patients present with hyperglycemia, yet little is known about the mechanism by which hyperglycemia affects hemorrhagic transformation (HT) and functional outcome in diabetics as compared to non-diabetics. Methods: We performed a retrospective review of consecutive ischemic stroke patients presenting to our comprehensive stroke center (CSC) from March 2014 to April 2015. Demographic, clinical, and neuroimaging data were collected. Patients were divided into four groups: (1) no type II diabetes (DM) with glucose on admission 180, (3) DM with glucose 180. Hemorrhagic transformation (HT) and poor functional outcome at discharge, as measured by modified Rankin scale (mRS) score 3-6, were compared amongst groups. Results: A total of 773 consecutive patients were admitted during the 14-month period (mean age 64, 49.3% women, and 36.6% Black). When compared to the reference group (n=467), patients without DM, but with glucose >180 (n=50) had higher odds of developing HT (OR 10.6, 95%CI 5.47-20.4, p180 (n=104) had higher odds of poor functional outcome even after adjusting for age, stroke severity, IV tPA use, and endovascular therapy (NIHSS, OR 1.88, CI 1.04-3.42, p=0.037). Conclusions: We observed that hyperglycemia on admission was associated with HT in non-diabetics and associated with poor functional outcome in diabetics. Reasons that diabetics with hyperglycemia do not experience HT remain unclear. A better understanding of the pathophysiology of acute hyperglycemia in patients with and without DM is needed in order to minimize the risk of HT and its adverse effects.

Background & Purpose: Recent studies have suggested a “smoker’s paradox,” referring to higher recanalization rates and better outcomes after IV thrombolytic therapy for ischemic stroke in smokers compared to nonsmokers. Our goal was to evaluate whether this paradox exists for both IV and endovascular therapies (ET) in our population. Methods: We retrospectively evaluated consecutive AIS patients (March 2014-April 2015) admitted to our comprehensive stroke center. Patients were stratified by treatment: IV tPA, ET, or neither. The primary endpoint was the modified Rankin scale (mRS) at discharge (“favorable outcome” score 0- 2) analyzed by logistic regression adjusted for demographic factors and admission NIHSS score. Successful reperfusion after ET was classified as Thrombolysis in Cerebral Infarction (TICI) scores of 2b or greater on immediate angiographic imaging. Results: Of 765 patients, 29 % were smokers (n= 222) including 63 % white (Table). Among smokers, 15% received tPA and 3% of patients received ET. Among nonsmokers 14% received tPA and 6% received ET. There was no difference in favorable outcome between smokers and nonsmokers in patients treated with tPA (60.6% vs. 52.6%; P= 0.43) or ET (26% vs. 40.0%; P= 0.325). There was no difference between smokers and nonsmokers in re-canalization after ET (70.6 % vs. 70.0%; P= 0.62). In patients without tPA or ET treatment, favorable outcome was more frequent in smokers compared to nonsmokers (66.5% vs. 47.8 %; P< 0.001). In a regression model adjusted for admission NIHSS, age, gender, and race, the prevalence of good outcome in smokers was 18% more than nonsmokers. (PR 1.177; 95% CI: 1.021 - 1.409). Conclusions: Our study did not support presence of the “Smoker’s Paradox” in AIS patients who receive IV or ET therapy. A rigorous adjustment for risk factors is likely to eliminate the paradoxical finding of more frequent favorable outcome in smokers who have not received tPA or ET.

Background and Purpose: Minimizing time from symptom onset to recanalization is crucial to maximizing outcome. Approaches to save time in ET cases including processes to reduce door-to-recanalization times need to be explored. Methods: We performed a retrospective review of consecutive ischemic stroke patients transferred to our comprehensive stroke center (CSC) from March 2014 to April 2015. Demographic and clinical data were collected. We compared adverse events (hemorrhagic transformation [HT], DVT, PE, urinary tract infection [UTI], pneumonia [PNA], bacteremia), door-to-recanalization time, and short-term outcomes in patients that were evaluated in the emergency department (ED) prior to ET and patients that were transferred directly to the endovascular suite, bypassing the ED. Results: Among the 776 consecutive ischemic stroke patients admitted to our center during the 14-month period, 7% (n=49) received acute ET. Twenty-six of these patients (53%) were transferred to our CSC for ET. Among transfers, 58% (n=15) bypassed the ED. Patients that bypassed the ED had a higher frequency of adverse events (53% vs. 27%, p=0.246), but shorter arrival to recanalization times when compared to patients that did not skip the ED (median 89 vs. 109 minutes p=0.637). Poor functional outcome, as measured by modified Rankin scale (mRS) score of 4-6, was similar between groups (67% vs. 64%, p=1.000), but in-hospital mortality was more frequent in the ED bypass group (33% vs. 18%, p=0.658). Conclusions: In our sample of acute ischemic patients transferred for acute ET, nearly 60% of patients bypassed the ED, reducing time to recanalization. This time savings was associated with a clinically higher proportion of adverse events. Standardized protocols for patients transferred to acute ET are needed to reduce time to recanalization without increasing adverse event rates.

Background: It is unknown what significance different initial Systolic Blood Pressure (SBP) values have for patients presenting with acute ischemic stroke (AIS). We investigated factors associated with admission SBP, including hemorrhagic transformation (HT) and discharge outcome. Methods: This is a retrospective study of consecutive AIS patients presenting from April 2014 to March 2015. Demographic and clinical data were collected, including admission SBP divided into three tiers: 165. Primary measure of outcome was in-hospital mortality. Results: A total of 776 patients were included with mean age 64, 49.2% females and 36.5% Black Race. Most patients with Black Race, hypertension (HTN) and hyperlipidemia (HLD) had SBP between 140-165 and >165, whereas most patients with heart failure had lower SBP (165 group. A similar number of patients amongst the three groups were on BP medications (63.5% vs. 69.3% vs. 64.1%), and there were no differences in proportion of HT (15.7% vs. 18.7% vs.12.6%). Although the proportion of patients treated with IV TPA were evenly distributed among tiers (14.4% vs. 13.6% vs. 15.7%), more patients with blood pressure 165 was associated with lower odds of in-hospital mortality (OR 0.536, 95%CI 0.295-0.975, p=0.041). This was significant after adjusting for age and NIHSS (OR 0.431, 95%CI 0.193-0.962, p=0.0399). Conclusions: Normal presenting SBP in patients with AIS was associated with in-hospital mortality. This may be related to heart failure. Further research is needed to define the ideal range to maintain SBP after AIS.

Background: Early ischemic changes (EIC) on head CT are associated with increased hemorrhagic transformation (HT) following treatment with TPA. We examined the associations between EIC, HT, and outcomes in patients treated and not treated with IV TPA. Methods: We conducted a retrospective review of consecutive acute ischemic stroke (AIS) patients presenting to our CSC from April 2014 to March 2015. Demographic and clinical data, including initial head CT findings (parenchymal hypodensity, loss of gray-white differentiation, sulcal effacement, hyperdense vessel) were collected. HT on repeat neuroimaging, poor functional outcome, as measured by a modified Rankin Scale (mRS) of 3-6, and in-hospital mortality were assessed. Results: A total of 679 patients were included (50.4% men). One hundred and eight patients (15.9%) received IV TPA. EIC were observed in 38.5% of untreated patients and 17.6% in IV TPA treated patients (p14 (14.8% vs. 9.6%, p=0.016), and discharge mRS 3-6 (53.6% vs. 44.5%, p=0.040). For patients treated with IV TPA, in-hospital mortality was more common in patients with EIC (31.6% vs. 10.0%, p=0.013). Conclusions: In untreated patients, EIC may serve as a harbinger for HT on repeat imaging and poor functional outcome at discharge, whereas in patients treated with IV TPA, it is associated with HT and in-hospital mortality. Patients with EIC may be at increased risk of HT and poor outcomes even without thrombolytics.

Background and Purpose: Palliative care (PC) should be an essential component of stroke care, particularly in patients with severe strokes given their poor prognosis and symptom burden. Despite the potential benefits of PC, a recent AHA scientific statement found that PC use in stroke was understudied and poorly understood. Methods: We performed a retrospective review of consecutive ischemic stroke patients presenting to our comprehensive stroke center (CSC) from 3/14-4/15. Demographic and clinical data were collected. We compared the proportion of patients that received an inpatient PC consult to the proportion of patients with a discharge modified Rankin scale (mRS) score of 4-6 (unable to walk without assistance and unable to attend to own bodily needs without assistance) by NIHSS score on admission. Results: Of the 776 ischemic stroke patients admitted to our CSC, only 6% received a palliative care consult. Even among the 254 patients discharged with a mRS of 4-6, only 16% received an PC consult. Figure 1 displays discharge mRS 4-6 and PC consult proportions by NIHSS severity. Patients that received a PC consult were older (median age 75 vs. 65, p Conclusions: Our observations suggest that PC may be underutilized in ischemic stroke patients, particularly in those who may benefit from it the most. PC has great potential to diminish suffering through physical and psychological symptom management. Providers should at least consider PC consults for hospitalized stroke patients.

Introduction: For each decade beyond age 55, the risk of ischemic stroke more than doubles; however, studies suggest that the elderly may receive acute treatments less frequently. Recently, several trials have shown benefit for endovascular thrombectomy (IA). Many of these trials included elderly patients. It remains unclear if previously described age disparities will continue to be seen as strategies for acute stroke therapy evolve. The purpose of this analysis was to establish the proportion of older adults that received acute revascularization treatment prior to the publication of these new endovascular trials. Methods: We used the National Inpatient Sample to obtain data on primary ischemic stroke diagnosis discharges from US hospitals between 2006 to 2011. Among these discharges, utilization of IV tPA or endovascular thrombectomy was identified using procedure codes. Discharges were further classified by age ≥75 and year. Results: Over the 6 year period, nearly half (47%) of the 2,592,269 ischemic stroke discharges were age 75 or older. Despite this, they represented only 27% of tPA administrations and 34% of endovascular procedures (Figure 1). For all ischemic stroke discharges during this period, tPA was administered in a lower proportion of patients ≥75 years compared to those Conclusions: Despite the fact that approximately half of stroke discharges were age 75 or older, they account for only about 30% of those receiving acute stroke therapies. As the US population ages, these findings raise concern that fewer older patients will receive the only acute therapies shown to improve functional outcome in ischemic stroke. Providers should be cognizant of potential age biases when selecting candidates for acute therapy and should continue to enroll the elderly in therapeutic trials.

Delirium in acute stroke has higher morbidity and mortality than those without delirium. This two-group randomized controlled trial (RCT) tests if a multicomponent intervention improves delirium outcomes in stroke patients at a comprehensive stroke center. This presentation describes the challenges in managing a RCT in acute stroke. Scientific rigor requires coordinating staff, enrolling adequate sample size, assuring intervention fidelity, and fostering data integrity. A sample of 282 subjects is required for 80% power (α=0.05) to determine a 10% reduction in incident delirium. Eligibility includes acute stroke, aged ≥ 50 years, no aphasia or delirium on admit. Subjects randomized to Usual Care (UC) or Delirium Care (DC). Both groups receive standardized Stroke Care. DC subjects receive a multicomponent intervention: 1) pharmacist recommendations using Anticholinergic Drug scale scores; and 2) therapeutic activities. NIHSS, Montreal Cognitive Assessment (MoCA), Confusion Assessment Method (CAM), and mRS are used to determine primary (delirium) and secondary endpoints (LOS, neurological deficit, functional status). A total of 513 patients screened over 289 consecutive days required unbudgeted staff. The 310 excluded [aphasia (94), baseline delirium (36), critically ill (92), LOS

The stroke system of care is undergoing significant evolution. There are promising data to suggest that with new technologies and approaches, primary prevention and community education will become easier and more accessible, and will allow people to have greater participation in their own healthcare. The evidence-based primary and comprehensive stroke center concepts have been translated into robust, rapidly growing certification programs. The continued dissemination of improved EMS routing protocols allows for better allocation of patients to stroke centers, even as we confront the challenge of further improving prehospital recognition of stroke. National quality improvement initiatives help to ensure that patients directed to stroke centers receive evidence-based treatment, which has resulted in improved stroke care and better clinical outcomes. In remote areas, the use of technologies such as telemedicine to extend the reach of vascular neurologists has resulted in increased administration of time-sensitive thrombolytic therapy and better patient outcomes, although greater efficiency within the stroke system will likely be needed to realize the potential benefits of endovascular therapy. System-level paradigms for aggressive medical management promise to lessen the burden of recurrent stroke. Finally, further integration of rehabilitation programs into stroke centers and coordination with community-based rehabilitation services is needed to ensure the best possible outcome for stroke patients.