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Background: Tenecteplase has potential benefits over alteplase, the standard agent for intravenous thrombolysis in acute ischaemic stroke, because it is administered as a single bolus and might have superior efficacy. The ATTEST-2 trial investigated whether tenecteplase was non-inferior or superior to alteplase within 4·5 h of onset., Methods: We undertook a prospective, randomised, parallel-group, open-label trial with masked endpoint evaluation in 39 UK stroke centres. Previously independent adults with acute ischaemic stroke, eligible for intravenous thrombolysis less than 4·5 h from last known well, were randomly assigned 1:1 to receive intravenous alteplase 0·9 mg/kg or tenecteplase 0·25 mg/kg, by use of a telephone-based interactive voice response system. The primary endpoint was the distribution of the day 90 modified Rankin Scale (mRS) score and was analysed using ordinal logistic regression in the modified intention-to-treat population. We tested the primary outcome for non-inferiority (odds ratio for tenecteplase vs alteplase non-inferiority limit of 0·75), and for superiority if non-inferiority was confirmed. Safety outcomes were mortality, symptomatic intracranial haemorrhage, radiological intracranial haemorrhage, and major extracranial bleeding. The trial was prospectively registered on ClinicalTrials.gov (NCT02814409)., Findings: Between Jan 25, 2017, and May 30, 2023, 1858 patients were randomly assigned to a treatment group, of whom 1777 received thrombolytic treatment and were included in the modified intention-to-treat population (n=885 allocated tenecteplase and n=892 allocated alteplase). The mean age of participants was 70·4 (SD 12·9) years and median National Institutes of Health Stroke Scale was 7 (IQR 5-13) at baseline. Tenecteplase was non-inferior to alteplase for mRS score distribution at 90 days, but was not superior (odds ratio 1·07; 95% CI 0·90-1·27; p value for non-inferiority<0·0001; p=0·43 for superiority). 68 (8%) patients in the tenecteplase group compared with 75 (8%) patients in the alteplase group died, symptomatic intracerebral haemorrhage (defined by SITS-MOST criteria) occurred in 20 (2%) versus 15 (2%) patients, parenchymal haematoma type 2 occurred in 37 (4%) versus 26 (3%) patients, post-treatment intracranial bleed occurred in 94 (11%) versus 78 (9%) patients, significant extracranial haemorrhage occurred in 13 (1%) versus six (1%) patients, respectively, and angioedema occurred in six (1%) participants in both groups., Interpretation: Tenecteplase 0·25 mg/kg was non-inferior to 0·9 mg/kg alteplase within 4·5 h of symptom onset in acute ischaemic stroke. Easier administration of tenecteplase, especially in the context of interhospital transfers, indicates that tenecteplase should be preferred to alteplase for thrombolysis in acute ischaemic stroke. The ATTEST-2 population was large and representative of thrombolysis-eligible patients in the UK and, together with findings from other trials, provides robust evidence supporting the introduction of tenecteplase in preference to alteplase., Funding: The Stroke Association and British Heart Foundation., Competing Interests: Declaration of interests KWM reports lecture and advisory board fees from Boehringer Ingelheim; lecture fees from Brainomix and IschemaView; and consultancy fees from Abbvie, Biogen, Hyperfine, Lumosa, and Woolsey. GAF reports personal remuneration for advisory board or steering committee activity from CSL Behring; educational activities from Bayer; and his employer (University of Oxford and Oxford University Hospitals NHS Foundation Trust) has received remuneration for consultancy with AstraZeneca. IF reports research grants to the University of Glasgow from The Stroke Association and the British Heart Foundation. JMW reports academic research grants but no industry, advisory or speaker fees or stock interests. AM reports research grants to the University of Glasgow from The Stroke Association and the British Heart Foundation. NG reports research grants to the University of Glasgow from The Stroke Association and the British Heart Foundation. GM reports personal remuneration for consultancy with Canon Medical Research Europe. MJM reports advisory board and educational meeting remuneration from Astra Zeneca. WNW reports drafting the European Stroke Organisation guideline for thrombolysis; and Data Monitoring Committee for TEMPO-2. AH reports being a clinical advisor to the Peninsula Technology Assessment Group, University of Exeter Medical School (External Advisory Group National Institute for Health & Care Excellence Technology Appraisal of Tenecteplase for treating acute ischaemic stroke, NICE reference number ID6306), all unpaid. MB reports research meeting remuneration for the LIBREXIA trial from Janssen and Bristol Myers Squibb. All other authors declare no competing interests., (Copyright © 2024 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background and Purpose: Ambulance trials assessing interventions in suspected stroke patients will recruit patients with currently active symptoms that will resolve into transient ischaemic attack (TIA). The safety and efficacy of glyceryl trinitrate (GTN) in the pre-specified subgroup of patients with TIA in the Rapid Intervention with Glyceryl Trinitrate in Hypertensive Stroke Trial 2 (RIGHT-2) was assessed., Methods: RIGHT-2 was a pre-hospital-initiated multicentre randomized sham-controlled blinded-endpoint trial that randomized patients with presumed ultra-acute stroke within 4 h of symptom onset to transdermal GTN or sham. Final diagnosis was determined by site investigators. The primary outcome was a shift in modified Rankin Scale (mRS) scores at 90 days analysed using ordinal logistic regression reported as adjusted common odds ratio with 95% confidence intervals (CIs). Secondary outcomes included death or dependence (mRS >2)., Results: In all, 109 of 1149 (9.5%) patients had a final diagnosis of TIA (GTN 57, sham 52) with mean age 73 (SD 13) years, 19 (17.4%) had pre-morbid mRS >2, and onset to randomization was 80 min (interquartile range 49, 105). GTN lowered blood pressure by 7.4/5.2 mmHg compared with sham by hospital arrival. At day 90, GTN had no effect on shift in mRS scores (common odds ratio for increased dependence 1.47, 95% CI 0.70-3.11) but was associated with increased death or dependence (mRS >2): GTN 29 (51.8%) versus sham 23 (46.9%), odds ratio 3.86 (95% CI 1.09-13.59)., Conclusions: Pre-hospital ultra-acute transdermal GTN did not improve overall functional outcome in patients with investigator-diagnosed TIA compared with sham treatment., (© 2024 The Author(s). European Journal of Neurology published by John Wiley & Sons Ltd on behalf of European Academy of Neurology.)

Introduction: Lacunar stroke represents around a quarter of all ischemic strokes; however, their identification with computed tomography in the hyperacute setting is challenging. We aimed to validate a clinical score to identify lacunar stroke in the acute setting, independently, with data from the WAKE-UP trial using magnetic resonance imaging., Methods: We analyzed data from the WAKE-UP trial and extracted Oxfordshire Community Stroke Project (OCSP) classification. Lacunar score was defined by National Institutes of Health Stroke Scale (NIHSS) < 7 and OCSP lacunar syndrome. Assessment of lacunar infarct by two independent investigators was blinded to clinical data. We calculated sensitivity, specificity, negative and positive predictive value (NPV and PPV, respectively) of lacunar score., Results: We included 503 patients in the analysis, mean (±SD) age 65.2 (±11.6) years, 325 (65%) males, median (IQR) NIHSS = 6 (4-9); 108 (22%) lacunar infarcts were identified on magnetic resonance (MR), patients fulfilling lacunar score criteria were 120 (24%), of which 47 (44%) had a lacunar infarct. Lacunar score was negative in 322 (82%) of patients without lacunar infarct. Patients with lacunar score had lower NIHSS (4 vs 7, p < 0.001), higher systolic (157 vs 151 mmHg, p = 0.001) and diastolic (86 vs 83 mmHg, p = 0.013) blood pressure and smaller infarct volume (2.4 vs 9.5 mL, p < 0.001). Performance of lacunar score was as follows: sensitivity 0.44; specificity 0.82; PPV 0.39; NPV 0.84; and accuracy 0.73. Assuming a prevalence of lacunar stroke of 13%, PPV lowered to 0.30 but NPV was 0.90. Lacunar score performed better for supratentorial lacunar infarcts., Conclusion: Lacunar score had a very good specificity and NPV for screening of lacunar stroke. Implementation of this simple tool into clinical practice may help hyperacute management and guide patient selection in clinical trials., Data Access Statement: Data supporting the results of this paper are available upon reasonable request to the corresponding author., Competing Interests: Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: G.T. received fees as consultant or lecturer from Acandis, Alexion, Amarin, Astra Zeneca, Bayer, Bristol Myers Squibb (BMS)/Pfizer, Boehringer Ingelheim, Daiichi Sankyo, and Stryker, all outside the submitted work. M.E. reports grants from Bayer and fees paid to the Charité from Abbott, Amgen, AstraZeneca, Bayer Healthcare, Boehringer Ingelheim, BMS, Daiichi Sankyo, Sanofi, Novartis, Pfizer, all outside the submitted work. The other authors report no conflict of interest.

Background: Functional outcomes in patients with acute ischemic stroke (AIS) with large vessel occlusion (LVO) undergoing endovascular treatment (EVT) with poor reperfusion were compared with patients with AIS-LVO treated with best medical management only., Methods: Data are from the HERMES collaboration, a patient-level meta-analysis of seven randomized EVT trials. Baseline characteristics and functional outcomes (modified Rankin Scale (mRS) score at 90 days) were compared between patients with poor reperfusion (defined as modified Thrombolysis in Cerebral Infarction Score 0-1 on the final intracranial angiography run as assessed by the central imaging core laboratory) and patients in the control arm with multivariable logistic ordinal logistic regression adjusted for pre-specified baseline variables., Results: 972 of 1764 patients from the HERMES collaboration were included in the analysis: 893 in the control arm and 79 in the EVT arm with final mTICI 0-1. Patients with poor reperfusion who underwent EVT had higher baseline National Institutes of Health Stroke Scale than controls (median 19 (IQR 15.5-21) vs 17 (13-21), P=0.011). They also had worse mRS at 90 days compared with those in the control arm in adjusted analysis (median 4 (IQR 3-6) vs median 4 (IQR 2-5), adjusted common OR 0.59 (95% CI 0.38 to 0.91)). Symptomatic intracranial hemorrhage was not different between the two groups (3.9% vs 3.5%, P=0.75, adjusted OR 0.94 (95% CI 0.23 to 3.88))., Conclusion: Poor reperfusion after EVT was associated with worse outcomes than best medical management, although no difference in symptomatic intracranial hemorrhage was seen. These results emphasize the need for additional efforts to further improve technical EVT success rates., Competing Interests: Competing interests: JO received consulting fees from Nicolab. SBB receives support from the University of Calgary and is on the data safety and monitoring advisory board of the TESLA study. RVM is a shareholder of Collavidence. MDH received support from Medtronic via a grant to the University of Calgary for the HERMES collaboration (now complete and inactive). He reports additional support from Boehringer Ingelheim to the University of Calgary for the TEMPO-2 trial, from Biogen to the University of Calgary, and from NoNo to the University of Calgary for the ESCAPE-NA1 trial and the ESCAPE-NEXT trial, as well as money from the Canadian Institutes for Health Research for the ESCAPE-NA1 and ESCAPE-NEXT trials, as well as from Alberta Innovates to the University of Calgary for the QuICR Alberta Stroke Program for the ESCAPE-NA1 trial. He additionally reports paid work for the adjudication of clinical trial outcomes from Sun Pharma and Brainsgate. He is on the data safety monitoring board for the RACECAT trial, Oncovir Hiltonel trial, DUMAS trial, ARTESIA trial, and BRAIN-AF trial. He is the president of the Canadian Neurological Sciences Federation and Canadian Stroke Consortium. He has private stocks in Circle Inc and PureWeb Inc. KWM has received grants from the British Heart Foundation, The Stroke Association, and Innovate UK for the ATTEST-2 and TEMPO-2 trials. He has accepted consulting fees from Boehringer-Ingelheim, Abbvie, and Biogen. He has received lecture fees from Boehringer Ingelheim. He is on the data safety and monitoring board of the ARREST trial. PJM has received royalties or licenses from Medtronic and Stryker for institutional research support, and support from Stryker, Medtronic, and Microvention for attending meetings and/or travel. MG has received grants from NoNo, Medtronic, and Cerenovus via the University of Calgary. He has received royalties or licenses from GE Healthcare and Microvention. He has received consulting fees from Microvention, Medtronic, Stryker, and Mentice. He has stock or stock options in Circle Neurovascular., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Clinicians need simple and highly predictive prognostic scores to assist practical decision-making. We aimed to develop a simple outcome prediction score applied 24 hours after anterior circulation acute ischemic stroke treatment with endovascular thrombectomy and validate it in patients treated both with and without endovascular thrombectomy., Methods: Using the HERMES (Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials) collaboration data set (n=1764), patients in the endovascular thrombectomy arm were divided randomly into a derivation cohort (n=430) and a validation cohort (n=441). From a set of candidate predictors, logistic regression modeling using forward variable selection was used to select a model that was both parsimonious and highly predictive for modified Rankin Scale (mRS) ≤2 at 90 days. The score was validated in validation cohort, control arm (n=893), and external validation cohorts from the ESCAPE-NA1 (Efficacy and Safety of Nerinetide for the Treatment of Acute Ischaemic Stroke; n=1066) and INTERRSeCT (Identifying New Approaches to Optimize Thrombus Characterization for Predicting Early Recanalization and Reperfusion With IV Alteplase and Other Treatments Using Serial CT Angiography; n=614)., Results: In the derivation cohort, we selected 2 significant predictors of mRS ≤2 (National Institutes of Health Stroke Scale score at 24 hours and age [β-coefficient, 0.34 and 0.06]) and derived the HERMES-24 score: age (years)/10+National Institutes of Health Stroke Scale score at 24 hours. The HERMES-24 score was highly predictive for mRS ≤2 (c-statistic 0.907 [95% CI, 0.879-0.935]) in the derivation cohort. In the validation cohort and the control arm, the HERMES-24 score predicts mRS ≤2 (c-statistic, 0.914 [95% CI, 0.886-0.944] and 0.909 [95% CI, 0.887-0.930]). Observed provability of mRS ≤2 ranged between 3.1% and 3.4% when HERMES-24 score ≥25, while it ranged between 90.6% and 93.0% when HERMES-24 score <10 in the derivation cohort, validation cohort, and control arm. The HERMES-24 score also showed c-statistics of 0.894 and 0.889 for mRS ≤2 in the ESCAPE-NA1 and INTERRSeCT populations., Conclusions: The post-treatment HERMES-24 score is a simple validated score that predicts a 3-month outcome after anterior circulation large vessel occlusion stroke regardless of intervention, which helps prognostic discussion with families on day 2., Competing Interests: Dr Brown reports consulting for B. Braun Interventional Systems, Inc, Medtronic, MicroVention, Inc, and the University of Calgary and is employed by BRIGHT Research Partners. Dr Goyal reports grants from Medtronic, Stryker, MicroVention, and Mentice; consulting for Stryker, Microvention, and Mentice; and a patent for systems and methods for acute stroke diagnosis with GE Healthcare. Dr Menon reports stock holdings in Circle Neurovascular Imaging and compensation from Roche and Boehringer Ingelheim. Dr Campbell reports grants from Covidien, Medtronic, and the National Health and Medical Research Council of Australia and fellowships from the National Heart Foundation of Australia, the National Stroke Foundation of Australia, and the Royal Australasian College of Physicians. Dr Mitchell reports consulting for Stryker and MicroVention and grants from Medtronic and Stryker. Dr Jovin reports consulting for Contego Medical; grants/contracts from Medtronic and Stryker; data safety monitoring board participation with Johnson & Johnson CERENOVUS; and stock holdings in Anaconda, Basking, Freeox Biotech, Galaxy, Gravity, Kandu, Methinks, Route92, StataDX, and Vizai. Dr Saver reports consulting for Abbott Laboratories, Aeromics, Biogen, Boehringer Ingelheim, BrainQ, BrainsGate, CSL Behring, Johnson & Johnson Health Care Systems, Medtronic, MindRhythm, Roche, and Stream Medical; data safety monitoring board participation with MIVI Neuroscience; and stock holdings in Neuronics Medical and Rapid Medical. Dr Muir reports consulting for Boehringer Ingelheim, Bayer, and Daiichi Sankyo. Dr White reports consulting for MicroVention and grants from the UK National Institutes for Health Research, MicroVention, Stryker, Medtronic, and Penumbra. Dr Bracard reports grants from the French Ministry of Health; others from GE Medical Systems; and nonfinancial support from MicroVention Europe. Dr Roos reports stock holdings in Nicolab. Dr van Zwam reports grants/contracts from Bayer HealthCare Pharmaceuticals, Stryker, and Johnson & Johnson; employment by Maastricht Universitair Medisch Centrum; and data safety monitoring board participation with Philips. Dr Hill reports consulting for BrainsGate; grants/contracts from Biogen, Boehringer Ingelheim, the Canadian Institutes of Health Research, Medtronic MicroVention, and NoNO; end point review committee participation with Merck; employment by the University of Calgary; and a patent for Systems and Methods for Assisting in Decision-Making and Triaging for Acute Stroke Patients with Circle Neurovascular Imaging. Dr Demchuk reports consulting for Boehringer Ingelheim, HLS Therapeutics, Hoffmann-La Roche, Medtronic, Nova-Signal, and Servier; data safety monitoring board participation with Philips and Lumosa; others from Novo Nordisk AS, Pfizer, and Astra Zeneca; and stock and patent for Stroke imaging software with Circle Neurovascular Imaging. The other authors report no conflicts.

Objective: For stroke patients with unknown time of onset, mismatch between diffusion-weighted imaging (DWI) and fluid-attenuated inversion recovery (FLAIR) magnetic resonance imaging (MRI) can guide thrombolytic intervention. However, access to MRI for hyperacute stroke is limited. Here, we sought to evaluate whether a portable, low-field (LF)-MRI scanner can identify DWI-FLAIR mismatch in acute ischemic stroke., Methods: Eligible patients with a diagnosis of acute ischemic stroke underwent LF-MRI acquisition on a 0.064-T scanner within 24 h of last known well. Qualitative and quantitative metrics were evaluated. Two trained assessors determined the visibility of stroke lesions on LF-FLAIR. An image coregistration pipeline was developed, and the LF-FLAIR signal intensity ratio (SIR) was derived., Results: The study included 71 patients aged 71 ± 14 years and a National Institutes of Health Stroke Scale of 6 (interquartile range 3-14). The interobserver agreement for identifying visible FLAIR hyperintensities was high (κ = 0.85, 95% CI 0.70-0.99). Visual DWI-FLAIR mismatch had a 60% sensitivity and 82% specificity for stroke patients <4.5 h, with a negative predictive value of 93%. LF-FLAIR SIR had a mean value of 1.18 ± 0.18 <4.5 h, 1.24 ± 0.39 4.5-6 h, and 1.40 ± 0.23 >6 h of stroke onset. The optimal cut-point for LF-FLAIR SIR was 1.15, with 85% sensitivity and 70% specificity. A cut-point of 6.6 h was established for a FLAIR SIR <1.15, with an 89% sensitivity and 62% specificity., Interpretation: A 0.064-T portable LF-MRI can identify DWI-FLAIR mismatch among patients with acute ischemic stroke. Future research is needed to prospectively validate thresholds and evaluate a role of LF-MRI in guiding thrombolysis among stroke patients with uncertain time of onset. ANN NEUROL 2024;96:321-331., (© 2024 American Neurological Association.)

Background: Almost half of acute ischemic stroke patients present with mild symptoms and there are large practice variations in their treatment globally. Individuals with an intracranial occlusion who present with minor stroke are at an increased risk of early neurological deterioration and poor outcomes. Individual patient data meta-analysis in the subgroup of patients with minor deficits showed benefit of alteplase in improving outcomes; however, this benefit has not been seen with intravenous alteplase in published randomized trials., Design: TEMPO-2 (A Randomized Controlled Trial of Tenecteplase Versus Standard of Care for Minor Ischemic Stroke With Proven Occlusion) is a prospective, open label with blinded outcome assessment, randomized controlled trial, designed to test the superiority of intravenous tenecteplase (0.25 mg/kg) over nonthrombolytic standard of care, with an estimated sample size of 1274 patients. Adult patients presenting with acute ischemic stroke with the National Institutes of Health Stroke Scale (NIHSS) ⩽ 5 and visible arterial occlusion or perfusion deficit within 12 h of onset are randomized to receive either tenecteplase (0.25 mg/kg) or standard of care. The primary outcome is return to baseline neurological functioning, measured by the modified Rankin scale (mRS) at 90 days. Safety outcomes include death and symptomatic hemorrhage (intra or extra-cranial). Other secondary outcomes include mRS 0-1, mRS 0-2, ordinal shift analysis of the mRS, partial, and full recanalization on follow-up computed tomography angiogram., Conclusion: Results of this trial will aid in determining whether there is benefit of using tenecteplase (0.25 mg/kg) in treating patients presenting with minor stroke who are at high risk of developing poor outcomes due to presence of an intracranial occlusion., Data Access Statement: Data will be available upon reasonable request., Competing Interests: Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: T.S.F. was site PI for TEMPO-2 at my institution; payments from CIHR and HSFC went to my institution. Outside of the submitted work, he has received in-kind study medication from Bayer and honoraria for advisory board work with HLS Therapeutics, Bayer Canada, Roche, AstraZeneca, and Novartis. He has done expert witness work and is on the board of DESTINE Health. A.Y.Y. holds a National New Investigator Award from the Heart & Stroke Foundation of Canada. Others have none to declare.

Background: Robust collateral circulation has been linked with better reperfusion and clinical outcomes. It remains unclear how individual assessments of collateral circulation may be translated into clinical practice., Methods: The pooled Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials (HERMES) angiography dataset was analyzed by a centralized, independent imaging core blinded to other clinical data. Conventional angiography was acquired immediately prior to endovascular therapy. Collaterals were graded with the American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology (ASITN) system and associated with baseline patient characteristics, reperfusion, and day 90 modified Rankin Score (mRS). Both 90-day all-cause mortality and day 90 mRS were modeled via multivariable logistic regression., Results: Angiography was available in 376/605 (62%) patients. Baseline ASPECTS (Alberta Stroke Program Early CT Score) (p=0.043), history of diabetes mellitus (p=0.048), site of occlusion (p<0.001), and degree of subsequent Thrombolysis in Cerebral Infarction (TICI) reperfusion (p<0.001) were associated with collateral grades. ASITN collateral grade was strongly associated with ordinal mRS from baseline to 90 days in an unadjusted analysis (p<0.001). Multivariable regression demonstrated that collateral status is a strong determinant of mRS outcome in the presence of other predictors (OR=1.37 per grade, 95% CI [1.05 to 1.74], p=0.018). By comparing ORs, 1 unit of ASITN was determined to be approximately equivalent to 4.5 points of NIHSS, 11 years of age, 1.5 points of ASPECTS, or 100 min less delay from onset to puncture, in terms of impact on mRS., Conclusions: Individual collateral physiology may contribute significantly to reperfusion success and clinical outcomes after acute ischemic stroke. Building a consensus for the role of angiographic collateral assessment in the allocation of adjuvant reperfusion therapies may help galvanize a precision medicine approach in stroke., Competing Interests: Competing interests: DSL reports having received grant funding from NINDS and consulting fees as an imaging core laboratory from Cerenovus, Genentech, Medtronic, Stryker, and Rapid Medical. RJ reports consulting with Phenox Medical, Microvention Terumo, and RapidPulse Inc. CBLMM reports having received grant funding from the CVON/Dutch Heart Foundation, Healthcare Evaluation Netherlands, European Commission, TWIN Foundation, and unrestricted grants from Stryker and Boehringer Ingelheim (all paid to institution) and is shareholder of Nicolab (minority interest). AvdL reports consulting fees from Stryker and grant funding from the Dutch Heart Foundation, AngioCare BV, Medtronic/Covidien/EV3®, MEDAC Gmbh/LAMEPRO, Penumbra Inc., Top Medical/Concentric, and Stryker, received by the Erasmus University Medical Center. LSR serves on a Data and Safety Monitoring Board (DSMB) for somatosensory evoked potentials (SEP) monitoring in patients with acute ischemic stroke and large anterior vessel occlusion undergoing endovascular thrombectomy. A clinical validation of the Brain20® medical device, Promise20. AD reports grants from the Dutch Heart Foundation, Brain Foundation Netherlands, The Netherlands Organisation for Health Research and Development, Health Holland Top Sector Life Sciences & Health and unrestricted grants from Penumbra Inc., Stryker, Medtronic, and Thrombolytic Science, all for research. JLS reports consulting fees for advising on rigorous and safe clinical trial design and conduct from Abbott, Acticor, Aeromics, Amgen, Argenica, Astrocyte, Bayer, Biogen, Boehringer Ingelheim, BrainsGate, BrainQ, CSL Behring, Filterlex, Genentech, Johnson & Johnson, MindRhythm, Medtronic, NeuroMerit, Neuronics, Novo Nordisk, Occlutech, Phenox, Phillips, QuantalX, Rapid Medical, Roche, and Stream Biomedical. PJM reports unrestricted institutional scientific grants from Stryker and Medtronic. KWM reports consultancies with Boehringer Ingelheim, Biogen, Hyperfine, and lecture fees from Boehringer Ingelheim, IschemaView, and Brainomix. PW discloses institutional research grant support within the last 2 years from Microvention Terumo. He declares the following relevant professional relationships: Chair of the European Society of Minimally Invasive Neurotherapeutics Guidelines Committee, sits on the Policy Working Group for Thrombectomy of NHS England, and represents the Royal College of Radiologists on the UK Intercollegiate Stroke Working party - none of these are associated with financial reimbursement. He reports the following modest consultancy work: member of Stryker’s Global Hemorrhagic Stroke Advisory Board and educational consultancy work for Microvention Terumo. He has no other interests to declare. MG reports being the principal investigator of an unrestricted research grant to the University of Calgary for the HERMES collaboration by Medtronic. He also reports consulting services with Medtronic, Stryker, Microvention, and Cerenovus, and a licensing agreement with GE Healthcare regarding systems of acute stroke diagnosis., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Individuals with minor ischaemic stroke and intracranial occlusion are at increased risk of poor outcomes. Intravenous thrombolysis with tenecteplase might improve outcomes in this population. We aimed to test the superiority of intravenous tenecteplase over non-thrombolytic standard of care in patients with minor ischaemic stroke and intracranial occlusion or focal perfusion abnormality., Methods: In this multicentre, prospective, parallel group, open label with blinded outcome assessment, randomised controlled trial, adult patients (aged ≥18 years) were included at 48 hospitals in Australia, Austria, Brazil, Canada, Finland, Ireland, New Zealand, Singapore, Spain, and the UK. Eligible patients with minor acute ischaemic stroke (National Institutes of Health Stroke Scale score 0-5) and intracranial occlusion or focal perfusion abnormality were enrolled within 12 h from stroke onset. Participants were randomly assigned (1:1), using a minimal sufficient balance algorithm to intravenous tenecteplase (0·25 mg/kg) or non-thrombolytic standard of care (control). Primary outcome was a return to baseline functioning on pre-morbid modified Rankin Scale score in the intention-to-treat (ITT) population (all patients randomly assigned to a treatment group and who did not withdraw consent to participate) assessed at 90 days. Safety outcomes were reported in the ITT population and included symptomatic intracranial haemorrhage and death. This trial is registered with ClinicalTrials.gov, NCT02398656, and is closed to accrual., Findings: The trial was stopped early for futility. Between April 27, 2015, and Jan 19, 2024, 886 patients were enrolled; 369 (42%) were female and 517 (58%) were male. 454 (51%) were assigned to control and 432 (49%) to intravenous tenecteplase. The primary outcome occurred in 338 (75%) of 452 patients in the control group and 309 (72%) of 432 in the tenecteplase group (risk ratio [RR] 0·96, 95% CI 0·88-1·04, p=0·29). More patients died in the tenecteplase group (20 deaths [5%]) than in the control group (five deaths [1%]; adjusted hazard ratio 3·8; 95% CI 1·4-10·2, p=0·0085). There were eight (2%) symptomatic intracranial haemorrhages in the tenecteplase group versus two (<1%) in the control group (RR 4·2; 95% CI 0·9-19·7, p=0·059)., Interpretation: There was no benefit and possible harm from treatment with intravenous tenecteplase. Patients with minor stroke and intracranial occlusion should not be routinely treated with intravenous thrombolysis., Funding: Heart and Stroke Foundation of Canada, Canadian Institutes of Health Research, and the British Heart Foundation., Competing Interests: Declaration of interests SBC received grant funding from the Canadian Institutes of Health Research (CIHR), Heart and Stroke Foundation of Canada (HSFC), and the British Heart Foundation (BHF) to complete the TEMPO-2 study. Boehringer Ingelheim provided off-the-shelf study drug (tenecteplase) for the study. JFA has received public research grants from the Spanish Ministry of Science, the regional health department, the European Commission, and a private research grant from AstraZeneca. He has received consultant or speaker fees from Pfizer-BMS, Medtronic, and Amgen, and travel support from Daiichi-Sankyo. KSB reports speaker fees from Boehringer Ingelheim and AstraZeneca. LC has received consulting or speakers fees from Roche. JF reports speaker fees from AstraZeneca, Bayer, BMS, Boehringer Ingelheim, Pfizer, Sankyo, and Daiichi. AG reports a grant from Microvention; speaker fees from Alexion, Biogen, and Servier Canada; and stock options for SnapDx and Collavidence. DG reports honoraria from Boehringer Ingelheim, Ipsen, and Eisai. MG reports grant funding from Medtronic and Cerenovus and consulting fees from Mentice, CSL Behring, MicroVention, and Medtronic. TSF participated in an advisory board for Roche. FL reports speaker fees and travel support from Boehringer Ingelheim. BKM has been paid honoraria from Boehringer Ingelheim and Roche. MM has received honoraria from Boehringer Ingelheim for participation at an advisory board on the approval of tenecteplase for treatment of acute ischaemic stroke. SOM has received speaker fees from Boehringer, Medtronic, Penumbra, Bayer, Pfizer, Novartis, Novo Nordisk, Servier, and Daiichi Sankyo. KWM reports grant funding from the BHF, and the Stroke Association; consultancy fees from Boehringer Ingelheim, Biogen, IschaemaView; lecture fees from Boehringer Ingelheim, IschaemaView, and Brainomix; and non-financial support (drug supply for ATTEST-2 trial) from Boehringer Ingelheim. MWP is on Boehringer Ingelheim Advisory Board for Metalyse in stroke. AP received speaker fees from Boehringer Ingelheim and travel support from AstraZeneca for attending a meeting. OMP-N has received speaker fees from Boehringer Ingelheim and AstraZeneca. RS is part funded by the UCLH Biomedical Research Centre. DS reports an unrestricted educational grant from Boehringer Ingelheim. MIW reports sponsorship or financial assistance to support attendance at scientific meetings from Boehringer Ingelheim, Bristol Myers Squibb, Daiichi Sankyo UK, and Bayer; honoraria for lectures given at education meetings from Boehringer Ingelheim, Bristol Myers Squibb, and AstraZeneca; and payment for participation in advisory panels from Boehringer Ingelheim and Daiichi Sankyo UK. DJW is the Co-principal Investigator for Health Research Board of Ireland, Award–Improving Pathways for Acute Stroke and Rehabilitation. AYXY reports salary support from the HSFC. MDH reports grant funding from CIHR, HSFC, Alberta Innovates, and study drug from Boehringer Ingelheim; grants from NoNo and Medtronic; consulting fees from Sun Pharma Brainsgate; and a DSMB member role on many stroke clinical trials., (Copyright © 2024 Elsevier Ltd. All rights reserved, including those for text and data mining, AI training, and similar technologies.)

Background: Ischemic stroke lesion volume at follow-up is an important surrogate outcome for acute stroke trials. We aimed to assess which differences in 48-hour lesion volume translate into meaningful clinical differences., Methods: We used pooled data from 7 trials investigating the efficacy of endovascular treatment for anterior circulation large vessel occlusion in acute ischemic stroke. We assessed 48-hour lesion volume follow-up computed tomography or magnetic resonance imaging. The primary outcome was a good functional outcome, defined as modified Rankin Scale (mRS) scores of 0 to 2. We performed multivariable logistic regression to predict the probability of achieving mRS scores of 0 to 2 and determined the differences in 48-hour lesion volume that correspond to a change of 1%, 5%, and 10% in the adjusted probability of achieving mRS scores of 0 to 2., Results: In total, 1665/1766 (94.2%) patients (median age, 68 [interquartile range, 57-76] years, 781 [46.9%] female) had information on follow-up ischemic lesion volume. Computed tomography was used for follow-up imaging in 83% of patients. The median 48-hour lesion volume was 41 (interquartile range, 14-120) mL. We observed a linear relationship between 48-hour lesion volume and mRS scores of 0 to 2 for adjusted probabilities between 65% and 20%/volumes <80 mL, although the curve sloped off for lower mRS scores of 0-2 probabilities/higher volumes. The median differences in 48-hour lesion volume associated with a 1%, 5%, and 10% increase in the probability of mRS scores of 0 to 2 for volumes <80 mL were 2 (interquartile range, 2-3), 10 (9-11), and 20 (18-23) mL, respectively. We found comparable associations when assessing computed tomography and magnetic resonance imaging separately., Conclusions: A difference of 2, 10, and 20 mL in 48-hour lesion volume, respectively, is associated with a 1%, 5%, and 10% absolute increase in the probability of achieving good functional outcome. These results can inform the design of future stroke trials that use 48-hour lesion volume as the primary outcome., Competing Interests: Disclosures Dr Rinkel is supported by the Niels Stensen Fellowship. Dr Ospel reports consulting fees from NICOLAB. Dr Brown reports consulting fees from the University of Calgary during the conduct of the HERMES (Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials) collaboration and reports consulting fees from MicroVention. Dr Goyal reports that Medtronic provided a grant to the University of Calgary and consulting fees from Medtronic, Philips, Microvention, Stryker, and Mentice. Dr Muir reports a grant from Boehringer-Ingelheim paid to the institution for support of the ATTEST-2 (Alteplase-Tenecteplase Trial Evaluation for Stroke Thrombolysis); consulting fees from Boehringer-Ingelheim, AbbVie, and Biogen; and British Heart Foundation-funded data safety and monitoring board participation (ARREST [Advanced Reperfusion Strategies for Patients With Out-of-Hospital Cardiac Arrest and Refractory Ventricular Fibrillation]). Dr White reports unrestricted grants from Stryker, Medtronic (Covidien), and Penumbra paid to the institution. Dr Jovin reports honoraria from Stryker, Silk Road Medical, Blockade Medical, FreeOx Biomedical, Route 92, Neurotrauma Science, vizai, Corindus, Anaconda, Medtronic, Contego, and Methinks as a consultant; and has consulted for Cerenovus as a steering committee member and Stryker Neurovascular as a principal investigator of DAWN (Clinical Mismatch in the Triage of Wake Up and Late Presenting Strokes Undergoing Neurointervention With Trevo) and AURORA (Analysis of Pooled Data From Randomized Studies of Thrombectomy More Than 6 Hours After Last Known Well). Dr Hill reports grant/contracts from Biogen Inc, Boehringer-Ingelheim, Canadian Institutes of Health Research, Micorvention, Medtronic, NoNO, Inc, consultant for Brainsgate Ltd, End point review committee at Merck, employment at the University of Calgary, and patent for stroke imaging software with Circle NVI. Dr Mitchell reports speaking engagements from Stryker and Medtronic and research institutional support from Stryker Neurovascular and Medtronic. Dr Saver is a consultant for Johnson & Johnson Health Care Systems, Inc, Medtronic USA, Inc, Boehringer-Ingelheim, MIVI Neuroscience, Stryker Corporation, Abbott Laboratories, Aeromics, Biogen, BrainQ, Brainsgate, CSL Behring, Roche, stock options (Rapid Medical, MindRhythm, Neuronics Medical). Dr Muir reports consulting for AbbVie, Biogen, Boehringer-Ingelheim, Woolsey Pharma and IschemiaView. Dr Jovin reports stock options from Anaconda, Freeox Biotech, Kandu, Galaxy, Methinks, Route92, vizai, consulting for Contego Medical, Inc, data and safety monitoring at Johnson & Johnson Cerenovus, grant/contract from Medtronic USA, Inc, Stryker and employment at Cooper University Healthcare. Dr Demchuk reports compensation from Boehringer-Ingelheim, HLS Therapeutics, Hoffman-Laroche, Medtronic, Nova-Signal, and Servier for consultant services, others from AstraZeneca, Novo Nordisk, and Pfizer, data safety monitoring board participation with Philips, and stock and patent for stroke imaging software with Circle NVI. Dr Majoie reports grants from the Dutch Heart Foundation, European Commission, Health Evaluation Netherlands, Stichting Toegepast Wetenschappelijk Instituut voor Neuro-modulatie Foundation (TWIN Foundation), and Stryker (all paid to institution); and is a (minority interest) shareholder of Nicolab. Dr Dippel reports unrestricted research grants from the Dutch Heart Foundation, Brain Foundation Netherlands, The Netherlands Organisation for Health Research and Development, Health Holland Top Sector Life Sciences and Health, and unrestricted grants from Medtronic, Penumbra, Stryker, Thrombolytic Science, and Cerenovus (all paid to institution).

Prcis: Most glaucoma patients with missed appointments report barriers to care and social risk factors. One third expressed interest in engaging with a patient navigator program. Most expressed interest in rescheduling., Purpose: The purpose of this study was to identify barriers to care among glaucoma patients with missed appointments and to assess their interest in a patient navigator program., Material and Methods: A cross-sectional study involving adult glaucoma patients from an academic eye center who missed their scheduled appointment between April 18 and July 25, 2022. Participants were surveyed about reasons for missed appointments, barriers to care, social risk factors, and interest in consulting with our patient navigator program., Results: Of 172 patients with a missed glaucoma appointment, 73% (126/172) were contacted, and 40% (51/126) of those completed the survey. Participant age averaged 67±14 years, half were female (25/51, 49%), and most identified as Black (27/51, 53%) or White (21/51, 40%). Barriers to seeing a doctor including difficulty scheduling appointments (13/51, 26%), transportation (12/51, 24%), and cost or insurance barriers (8/51, 16%). Twenty-eight (55%) respondents reported at least one social risk factor. A positive association was found between having at least one risk factor and expressing interest in consulting our patient navigator (odds ratio=6.7, P =0.009). Overall, a third of respondents expressed interest in engaging with our patient navigator program (17/51, 33%). Two thirds of participants reported awareness of missed appointments (34/51, 67%), of whom 35% (12/34) reported having already rescheduled, 41% (14/34) expressed interest in rescheduling, and 24% (8/34) did not wish to return., Conclusions: Glaucoma patients with missed appointments report barriers to care and face social risk factors. Telephone outreach may help to re-engage them with care, and patients expressed interest in a patient navigator program to address social needs., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Blood Pressure Variability (BPV) is associated with cardiovascular risk and serum uric acid level. We investigated whether BPV was lowered by allopurinol and whether it was related to neuroimaging markers of cerebral small vessel disease (CSVD) and cognition. We used data from a randomised, double-blind, placebo-controlled trial of two years allopurinol treatment after recent ischemic stroke or transient ischemic attack. Visit-to-visit BPV was assessed using brachial blood pressure (BP) recordings. Short-term BPV was assessed using ambulatory BP monitoring (ABPM) performed at 4 weeks and 2 years. Brain MRI was performed at baseline and 2 years. BPV measures were compared between the allopurinol and placebo groups, and with CSVD and cognition. 409 participants (205 allopurinol; 204 placebo) were included in the visit-to-visit BPV analyses. There were no significant differences found between placebo and allopurinol groups for any measure of visit-to-visit BPV. 196 participants were included in analyses of short-term BPV at week 4. Two measures were reduced by allopurinol: the standard deviation (SD) of systolic BP (by 1.30 mmHg (95% confidence interval (CI) 0.18-2.42, p = 0.023)); and the average real variability (ARV) of systolic BP (by 1.31 mmHg (95% CI 0.31-2.32, p = 0.011)). There were no differences in other measures at week 4 or in any measure at 2 years, and BPV was not associated with CSVD or cognition. Allopurinol treatment did not affect visit-to-visit BPV in people with recent ischemic stroke or TIA. Two BPV measures were reduced at week 4 by allopurinol but not at 2 years., (© 2024. The Author(s).)

Purpose: To evaluate the diagnostic performance of a robotically aligned optical coherence tomography (RAOCT) system coupled with a deep learning model in detecting referable posterior segment pathology in OCT images of emergency department patients., Methods: A deep learning model, RobOCTNet, was trained and internally tested to classify OCT images as referable versus non-referable for ophthalmology consultation. For external testing, emergency department patients with signs or symptoms warranting evaluation of the posterior segment were imaged with RAOCT. RobOCTNet was used to classify the images. Model performance was evaluated against a reference standard based on clinical diagnosis and retina specialist OCT review., Results: We included 90,250 OCT images for training and 1489 images for internal testing. RobOCTNet achieved an area under the curve (AUC) of 1.00 (95% confidence interval [CI], 0.99-1.00) for detection of referable posterior segment pathology in the internal test set. For external testing, RAOCT was used to image 72 eyes of 38 emergency department patients. In this set, RobOCTNet had an AUC of 0.91 (95% CI, 0.82-0.97), a sensitivity of 95% (95% CI, 87%-100%), and a specificity of 76% (95% CI, 62%-91%). The model's performance was comparable to two human experts' performance., Conclusions: A robotically aligned OCT coupled with a deep learning model demonstrated high diagnostic performance in detecting referable posterior segment pathology in a cohort of emergency department patients., Translational Relevance: Robotically aligned OCT coupled with a deep learning model may have the potential to improve emergency department patient triage for ophthalmology referral.

Background: Recruitment of participants is the greatest risk to completion of most clinical trials, with 20-40% of trials failing to reach the targeted enrollment. This is particularly true of trials of central nervous system (CNS) therapies such as intervention for chronic stroke. The PISCES III trial was an invasive trial of stereotactically guided intracerebral injection of CTX0E03, a fetal derived neural stem cell line, in patients with chronic disability due to ischemic stroke. We report on the experience using a novel hybrid recruitment approach of a patient-facing portal to self-identify and perform an initial screen for general trial eligibility (tier 1), followed by phone screening and medical records review (tier 2) prior to a final in-person visit to confirm eligibility and consent., Methods: Two tiers of screening were established: an initial screen of general eligibility using a patient-facing web portal (tier 1), followed by a more detailed screen that included phone survey and medical record review (tier 2). If potential participants passed the tier 2 screen, they were referred directly to visit 1 at a study site, where final in-person screening and consent were performed. Rates of screening were tracked during the period of trial recruitment and sources of referrals were noted., Results: The approach to screening and recruitment resulted in 6125 tier 1 screens, leading to 1121 referrals to tier 2. The tier 2 screening resulted in 224 medical record requests and identification of 86 qualifying participants for referral to sites. The study attained a viable recruitment rate of 6 enrolled per month prior to being disrupted by COVID 19., Conclusions: A tiered approach to eligibility screening using a hybrid of web-based portals to self-identify and screen for general eligibility followed by a more detailed phone and medical record review allowed the study to use fewer sites and reduce cost. Despite the difficult and narrow population of patients suffering moderate chronic disability from stroke, this strategy produced a viable recruitment rate for this invasive study of intracranially injected neural stem cells., Trial Registration: ClinicalTrials.gov Identifier: NCT03629275., (© 2024. The Author(s).)

Background: The effect of transdermal glyceryl trinitrate (GTN, a nitrovasodilator) on clinical outcome when administered before hospital admission in suspected stroke patients is unclear. Here, we assess the safety and efficacy of GTN in the prespecified subgroup of patients who had an ischaemic stroke within the Rapid Intervention with Glyceryl trinitrate in Hypertensive stroke Trial-2 (RIGHT-2)., Methods: RIGHT-2 was an ambulance-based multicentre sham-controlled blinded-endpoint study with patients randomised within 4 hours of onset. The primary outcome was a shift in scores on the modified Rankin scale (mRS) at day 90. Secondary outcomes included death; a global analysis (Wei-Lachin test) containing Barthel Index, EuroQol-5D, mRS, telephone interview for cognitive status-modified and Zung depression scale; and neuroimaging-determined 'brain frailty' markers. Data were reported as n (%), mean (SD), median [IQR], adjusted common OR (acOR), mean difference or Mann-Whitney difference (MWD) with 95% CI., Results: 597 of 1149 (52%) patients had a final diagnosis of ischaemic stroke; age 75 (12) years, premorbid mRS>2 107 (18%), Glasgow Coma Scale 14 (2) and time from onset to randomisation 67 [45, 108] min. Neuroimaging 'brain frailty' was common: median score 2 [2, 3] (range 0-3). At day 90, GTN did not influence the primary outcome (acOR for increased disability 1.15, 95% CI 0.85 to 1.54), death or global analysis (MWD 0.00, 95% CI -0.10 to 0.09). In subgroup analyses, there were non-significant interactions suggesting GTN may be associated with more death and dependency in participants randomised within 1 hour of symptom onset and in those with more severe stroke., Conclusions: In patients who had an ischaemic stroke, ultra-acute administration of transdermal GTN in the ambulance did not improve clinical outcomes in a population with more clinical and radiological frailty than seen in previous in-hospital trials., Competing Interests: Competing interests: JPA is supported by an NIHR Health and Care Research Scholarship. PMB is Stroke Association Professor of Stroke Medicine and an NIHR Senior Investigator. TR is a NIHR Senior Investigator. GM is the Stroke Association Edith Murphy Foundation Senior Clinical Lecturer (SA L-SMP 18\1000). JW is supported by the UK Dementia Research Institute which receives its funding from DRI, funded by the UK Medical Research Council, Alzheimer’s Society and Alzheimer’s Research UK. The remaining authors report no declarations of interest., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background/objectives: Little is known about African American patient-provider communication about glaucoma-related quality-of-life. The objectives of this study were to: (a) examine associations between patient socio-demographics and vision quality-of-life, (b) describe the extent to which eye care providers and patients discuss glaucoma-related quality-of-life, and (c) examine associations between patient and provider characteristics, whether the patient was in the intervention or usual care group, and whether the patient and provider discuss one or more glaucoma-related quality-of-life domains., Methods: Adult African American patients with glaucoma who reported non-adherence to glaucoma medications were enrolled from three sites. Patients completed a vision quality-of-life VFQ-25 assessment. Patients were randomized into intervention and control groups with intervention group members receiving a glaucoma question prompt list and watching a video before a provider visit. Audio recordings from these visits were transcribed and assessed for glaucoma-related quality-of-life discussions., Results: One hundred and eighty-nine patients were enrolled. Glaucoma-related quality-of-life was discussed during 12.3% of visits (N = 23). Patients initiated discussion 56.5% (N = 13) of the time and providers 43.5% (N = 10) of the time. Patients with worse health literacy (p < 0.001), more depressive symptoms (p < 0.05), and more severe glaucoma (p < 0.001) were significantly more likely to have worse vision-related quality-of-life. Glaucoma-related quality-of-life was significantly more likely to be discussed when African American patients saw African American providers (p < 0.05)., Conclusion: Patients and providers rarely discussed the patient's glaucoma-related quality-of-life. The intervention did not significantly increase communication about glaucoma-related quality-of-life. Residency programs should consider enhancing training regarding discussing patients' quality-of-life., (© 2023. The Author(s), under exclusive licence to The Royal College of Ophthalmologists.)

Purpose: The objective of this study was to describe what questions patients checked on a glaucoma question prompt list and how often patients asked the same checked questions during medical visits., Design: A randomized controlled trial was conducted to test the effectiveness of a pre-visit video/glaucoma question prompt list intervention to increase African American patient question-asking during medical visits., Methods: Adult African American patients with glaucoma and a history of non-adherence to glaucoma medications were enrolled and randomized into intervention and usual care groups from three glaucoma practices. Visits were audio-recorded, transcribed, and coded for the questions patients asked during their visits. Researchers collected the pre-visit question prompt lists from the intervention group and compared their checked questions to the questions patients asked during their visit., Results: Ninety-three subjects were randomized to the question prompt list intervention group. Subjects checked an average of 6.77 questions on the prompt list. Of the subjects who checked at least one question, 54.8% asked their provider at least one of the questions they checked. The most common questions asked about glaucoma medications that they had checked were "What time(s) of day should I take my drops?" (50.0%, 9 out of 18) and "How many times a day do I use my glaucoma medicines?" (50.0%, 3 out of 6)., Conclusion: Although African American subjects with glaucoma have questions about glaucoma and their medications, few asked all their questions during visits. Future research should focus on how to improve question asking using a question prompt list., (© 2023. The Author(s), under exclusive licence to The Royal College of Ophthalmologists.)

Purpose: The objectives of this study were to conduct a randomized controlled trial testing the effectiveness of a previsit glaucoma video/question prompt list intervention, and to examine the impact on how often providers educate Black patients about glaucoma and glaucoma medication topics during visits., Design: A randomized controlled trial of a glaucoma question prompt list/video intervention., Participants: Black patients with a diagnosis of glaucoma who are taking 1 or more glaucoma medications and report being nonadherent., Methods: One hundred eighty-nine Black patients with glaucoma were enrolled and assigned to either a usual care or an intervention group where they watched a video emphasizing the importance of asking questions and received a glaucoma question prompt list to complete before clinic visits. Visits were audio-taped and patients were interviewed after visits., Main Outcome Measures: Whether the provider educates about different glaucoma and glaucoma medication topics., Results: Patients in the intervention group were significantly more likely to ask providers 1 or more questions about glaucoma and its treatment. Providers were significantly more likely to educate intervention patients about their diagnosis (P = 0.001), intraocular pressure (P = 0.03), the likelihood of the need for long-term therapy (P = 0.001), and the physical changes associated with glaucoma (P = 0.001) than usual-care patients. Providers were also significantly more likely to educate intervention patients about the purpose of their medications (P = 0.03) and side effects (P = 0.001) than usual-care patients. Providers only educated 29% of patients about adherence (33% of intervention group patients and 25% of usual-care patients). Few providers educated patients about barriers and fears/concerns in using glaucoma medications, the cost of medications and insurance coverage, how to administer eye drops, and nasolacrimal occlusion., Conclusions: The intervention significantly increased provider education about many glaucoma and glaucoma medication topics., Financial Disclosure(s): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article., (Copyright © 2023 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Background: The extent and distribution of intracranial hemorrhage (ICH) directly affects clinical management. Artificial intelligence (AI) software can detect and may delineate ICH extent on brain CT. We evaluated e-ASPECTS software (Brainomix Ltd.) performance for ICH delineation., Methods: We qualitatively assessed software delineation of ICH on CT using patients from six stroke trials. We assessed hemorrhage delineation in five compartments: lobar, deep, posterior fossa, intraventricular, extra-axial. We categorized delineation as excellent, good, moderate, or poor. We assessed quality of software delineation with number of affected compartments in univariate analysis (Kruskall-Wallis test) and ICH location using logistic regression (dependent variable: dichotomous delineation categories 'excellent-good' versus 'moderate-poor'), and report odds ratios (OR) and 95 % confidence intervals (95 %CI)., Results: From 651 patients with ICH (median age 75 years, 53 % male), we included 628 with assessable CTs. Software delineation of ICH extent was 'excellent' in 189/628 (30 %), 'good' in 255/628 (41 %), 'moderate' in 127/628 (20 %), and 'poor' in 57/628 cases (9 %). The quality of software delineation of ICH was better when fewer compartments were affected (Z = 3.61-6.27; p = 0.0063). Software delineation of ICH extent was more likely to be 'excellent-good' quality when lobar alone (OR = 1.56, 95 %CI = 0.97-2.53) but 'moderate-poor' with any intraventricular (OR = 0.56, 95 %CI = 0.39-0.81, p = 0.002) or any extra-axial (OR = 0.41, 95 %CI = 0.27-0.62, p<0.001) extension., Conclusions: Delineation of ICH extent on stroke CT scans by AI software was excellent or good in 71 % of cases but was more likely to over- or under-estimate extent when ICH was either more extensive, intraventricular, or extra-axial., Competing Interests: Declaration of Competing Interest GM: Consultancy fees from Canon Medical for stroke imaging software development. KWM: Institution has research agreement with Brainomix. PMB is Stroke Association Professor of Stroke Medicine and an emeritus NIHR Senior Investigator. PMW has no relevant disclosures. He reports institutional educational grants from Medtronic, Stryker and Penumbra in the last 3 years., (Copyright © 2023. Published by Elsevier Inc.)