Search

Background and ObjectivesThere have been numerous reports of neurologic manifestations identified in hospitalized patients infected with SARS-CoV-2, the virus that causes COVID-19. Here, we identify the spectrum of associated neurologic symptoms and diagnoses, define the time course of their development, and examine readmission rates and mortality risk posthospitalization in a multiethnic urban cohort.MethodsWe identify the occurrence of new neurologic diagnoses among patients with laboratory-confirmed SARS-CoV-2 infection in New York City. A retrospective cohort study was performed on 532 cases (hospitalized patients with new neurologic diagnoses within 6 weeks of positive SARS-CoV-2 laboratory results between March 1, 2020, and August 31, 2020). We compare demographic and clinical features of the 532 cases with 532 controls (hospitalized COVID-19 patients without neurologic diagnoses) in a case-control study with one-to-one matching and examine hospital-related data and outcomes of death and readmission up to 6 months after acute hospitalization in a secondary case-only analysis.ResultsAmong the 532 cases, the most common new neurologic diagnoses included encephalopathy (478, 89.8%), stroke (66, 12.4%), and seizures (38, 7.1%). In the case-control study, cases were more likely than controls to be male (58.6% vs 52.8%, p = 0.05), had baseline neurologic comorbidities (36.3% vs 13.0%, p < 0.0001), and were to be treated in an intensive care unit (62.0% vs 9.6%, p < 0.0001). Of the 394 (74.1%) cases who survived acute hospitalization, more than half (220 of 394, 55.8%) were readmitted within 6 months, with a mortality rate of 23.2% during readmission.DiscussionHospitalized patients with SARS-CoV-2 and new neurologic diagnoses have significant morbidity and mortality postdischarge. Further research is needed to define the effect of neurologic diagnoses during acute hospitalization on longitudinal post-COVID-19–related symptoms including neurocognitive impairment.

Background: Cognitive impairment is prevalent in the heart failure (HF) population, eventually complicating the disease course in over 50%. Disease management and risk factor control are thought to play a role. Disparities in healthcare utilization and access may also contribute. We hypothesize gender, ethnic and racial disparities in HF contribute to accelerated cognitive decline. Methods: We performed a cross-sectional analysis of study participants age ≥ 60 years in the biannual NHANES survey. Medical history, clinical variables, and Digit Symbol Substitution Test (DSST) scores from cycles 1999, 2001, 2011, and 2013 were extracted. The DSST assesses visuomotor, attention, and processing speed, and in prior studies was found to be strongly associated with vascular-related cognitive impairment. Survey-weighted regression models adjusting for age, race, gender, education, vascular risk factors and history of stroke were used to generate nationally representative estimates. Results: 6,651 study participants representing 51,841,223 adults ≥ 60 years were included, 7% with prevalent HF. Participants with HF were older (73.8 vs 70.0, P Conclusions: Women with HF experience greater levels of HF-related cognitive impairment. These differences may be a consequence of known differential rates of early HF detection and disease maintenance across genders.

Background: Left ventricular assist devices (LVADs) are an established durable and lifesaving treatment option for patients with advanced heart failure. However, large vessel occlusions (LVOs) remain one of its most devastating embolic complications. Mechanical thrombectomy (MT) is safe and effective in the management of LVOs in the general population but LVO trials largely excluded patients on mechanical circulatory support and large-scale analyses of outcomes following these interventions in the LVAD population are lacking. Methods: Using the National Inpatient Sample (2012 - 2018) we identified all adult patients hospitalized with acute ischemic stroke (AIS). The presence of LVAD, the use of MT, and additional covariates were extracted. Descriptive statistics and multivariable regression models were used to compare outcomes following MT in patients with and without LVADs. Results: Of the 798,059 AIS hospitalizations identified, 366 occurred in patients with LVADs. LVAD patients were younger (mean age 59.6 [13.2] vs 70.1 [14.3], p Conclusion: Our data suggests MT is not a futile treatment approach in patients with LVADs and may result in similar rates of good outcomes. Additional research is needed to evaluate the long-term benefits of endovascular therapy after stroke in patients on LVAD support.

Background: Ethnic and racial disparities in healthcare contribute to cardiovascular morbidity and mortality. Stroke is prevalent among patients with heart failure (HF) and is associated with worse long-term outcomes. We hypothesized that disparities in cardiovascular risk profiles contribute to differences in stroke prevalence among patients with HF. Methods: We performed a cross-sectional analysis of study participants age ≥ 60 in the biannual NHANES survey. Medical history and clinical variables were obtained from cycles 1999, 2001, 2011, and 2013. We created survey-weighted regression models to generate nationally representative estimates. Results: A total of 20,315 study participants representing 212,156,242 adults were included, 2.5% with prevalent HF. Compared to those without HF, participants with HF were more often of White race (72.8% vs 68.3%, P = 0.02) and less often of Hispanic ethnicity (10.4% vs 14.3%, P = 0.04). Stroke was 10 times more prevalent among individuals with HF (20% vs 2%, P Conclusion: People of Hispanic ethnicity with HF have a higher prevalence of stroke which is not explained by vascular risk profiles and warrants further investigation.

Introduction: Recent work has demonstrated the safety and feasibility of rapid outpatient evaluation for presentations of TIA and non-disabling stroke. Our outpatient TIA and stroke clinic, Rapid Access Vascular Evaluation-Neurology (RAVEN) clinic, instituted in 2016, encountered unprecedented challenges in operations during the COVID-19 surge in New York City, leading to the creation of a telemedicine approach to minimize patient and staff exposure risk. To date, few virtual TIA/stroke clinics have reported on safety and feasibility outcomes. Hypothesis: We hypothesized that rapid follow-up of patients with suspected TIA and minor stroke via telemedicine would be feasible and safe during the pandemic. Methods/Results: We performed a retrospective chart review of patients with TIA and minor stroke who were referred to the virtual clinic from the emergency department (ED) between March and June 2020 (the local peak of the COVID-19 pandemic) when RAVEN in-person visits were suspended. A total of 24 patients were discharged early from the ED and referred for RAVEN evaluation with 20 patients evaluated as scheduled; 4 were lost to RAVEN follow-up. Ultimately, 60% of these patients were diagnosed with TIA or minor stroke after completing their remote evaluation; the rest were diagnosed as stroke mimics (seizure, migraine with aura, neuropathy, peripheral vertigo, stroke recrudescence). The median NIHSS calculated at initial ED evaluation was 1 with a maximum NIHSS of 5. A new medical intervention for secondary prevention was prescribed for 70% of patients prior to ED discharge. Amongst patients contacted by phone 3-5 months post-RAVEN evaluation, 4 of 15 had an increased modified Rankin score. Of the 24 patients referred for RAVEN evaluation, 7 returned to the ED within 90 days, with 3 patients citing neurologic complaints. On follow-up via phone conducted 2-5 months after RAVEN evaluation, 3 of 17 patients self-reported either a positive COVID-19 test or suspected COVID-19 diagnosis over the study period. Conclusion: A telemedicine-based approach to evaluate TIA and stroke in the RAVEN model helped limit patient infection risk, optimize resource allocation, establish accurate, timely diagnoses, and effectively implement secondary prevention strategies.

Introduction: The healthcare system was facing two challenges: acute patients presenting to the adult emergency department diagnosed with Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2)/ COVID-19 and how to treat life-threating emergencies. Emergency, neurovascular and multidisciplinary teams, therefore, had to be ready to treat these emergencies rapidly and safely. The goals were to balance substantial needs and preserve resources during this extraordinary time for incoming acutely ill patients. Background: The World Health Organization (WHO) defined COVID-19 as a pandemic. New York City was the epicenter for the 2019-2020 COVID -19 pandemic. There were 30,000 confirmed cases resulting in over 2,500 hospitalizations as of March 30, 2020. Hence, it was vital to develop new monitoring protocols, based upon the expert opinion of the stroke and multidisciplinary leadership at New York Presbyterian Hospital that required minimum monitoring and criteria for admission necessary to safely care for complex stroke patients. Purpose: This quality improvement project evaluated patient outcomes after the implementation of the modified stroke protocol. Methods: Retrospective data review was conducted for patients who presented via the Emergency Department with stroke symptoms, and were treated with intravenous thrombolysis (IVT) between 3/30 and 6/30/2020, with a focus on whether patients required a higher level of care or developed hemorrhagic transformation post IVT. Results: The sample consisted of 10 patients (60% female), median age 54 (range 37-73). Length of stay ranged from 2 to 12 days. Two patients (20%) were SARS-CoV-2 positive. None (0%) of the patients developed hemorrhagic transformation. None (0%) of the patients admitted to non-ICU units required critical care transfer or interventions within 24 hours of receiving IVT. Six (60%) patients were discharged to home. Conclusions: Using the modified patient monitoring protocol post IVT none of the patients developed symptomatic hemorrhagic transformation and did not require transfer to higher level of care within 24 hours. If there is another wave of the COVID-19 pandemic, this protocol could be adopted and its effectiveness and safety can continue to be evaluated.

Background and Purpose: To assess the effect of combination antiplatelet therapy with aspirin and clopidogrel versus aspirin alone on disability following TIA or minor stroke and to identify factors associated with disability. Methods: The POINT trial randomized patients with TIA or minor stroke (NIHSS≤3) within 12 hours of onset to dual antiplatelet therapy (DAPT) with aspirin plus clopidogrel versus aspirin alone. The primary outcome measure was a composite of stroke, MI, or vascular death. We performed a post-hoc exploratory analysis to examine the effect of treatment on overall disability (defined as mRS>1) at 90 days as well as disability ascribed by the local investigator to index or recurrent stroke. We also evaluated predictors of disability. Results: At 90 days, 188/1964 (9.6%) of patients enrolled with TIA and 471/2586 (18.2%) of those enrolled with stroke were disabled. Overall disability was similar between patients assigned DAPT versus aspirin alone (14.7% vs. 14.3%, OR 0.97, 95%CI 0.82-1.14, p=0.69). However, there were numerically fewer patients with disability in conjunction with a primary outcome event in the DAPT arm (3.0% vs. 4.0%, OR 0.73, 95%CI 0.53-1.01, p=0.06), and significantly fewer patients in the DAPT arm with disability attributed by the investigators to either the index event or recurrent stroke (5.9% vs. 7.4%, OR 0.78, 95% CI 0.62-0.99, p=0.04). Notably, disability attributed to the index event accounted for the majority of this difference (4.5% vs. 6.0%, OR 0.74 95% CI 0.57-0.96, p=0.02). In multivariate analysis of patients enrolled with TIA, disability was significantly associated with age, subsequent ischemic stroke, serious adverse events, and major bleeding. In patients enrolled with stroke, disability was associated with female sex, hypertension, diabetes, NIHSS score, recurrent ischemic stroke, subsequent myocardial infarction, and serious adverse events. Conclusions: In addition to reducing recurrent stroke in patients with acute minor stroke and TIA, dual antiplatelet therapy might reduce stroke-related disability.

Background and Purpose— Human immunodeficiency virus (HIV) infection has been shown to increase both ischemic and hemorrhagic stroke risks, but there are limited data on the safety and outcomes of intravenous thrombolysis with tPA (tissue-type plasminogen activator) for acute ischemic stroke in HIV-infected patients. Methods— A retrospective chart review of intravenous tPA-treated HIV patients who presented with acute stroke symptoms was performed in 7 large inner-city US academic centers (various search years between 2000 and 2017). We collected data on HIV, National Institutes of Health Stroke Scale score, ischemic stroke risk factors, opportunistic infections, intravenous drug abuse, neuroimaging findings, and modified Rankin Scale score at last follow-up. Results— We identified 33 HIV-infected patients treated with intravenous tPA (mean age, 51 years; 24 men), 10 of whom were stroke mimics. Sixteen of 33 (48%) patients had an HIV viral load less than the limit of detection while 10 of 33 (30%) had a CD4 count 3 . The median National Institutes of Health Stroke Scale score at presentation was 9, and mean time from symptom onset to tPA was 144 minutes (median, 159). The median modified Rankin Scale score for the 33-patient cohort was 1 and for the 23-patient actual stroke cohort was 2, measured at a median of 90 days poststroke symptom onset. Two patients had nonfatal hemorrhagic transformation (6%; 95% confidence interval, 1%–20%), both in the actual stroke group. Two patients had varicella zoster virus vasculitis of the central nervous system, 1 had meningovascular syphilis, and 7 other patients were actively using intravenous drugs (3 cocaine, 1 heroin, and 3 unspecified), none of whom had hemorrhagic transformation. Conclusions— Most HIV-infected patients treated with intravenous tPA for presumed and actual acute ischemic stroke had no complications, and we observed no fatalities. Stroke mimics were common, and thrombolysis seems safe in this group. We found no data to suggest an increased risk of intravenous tPA-related complications because of concomitant opportunistic infections or intravenous drug abuse.

Background Previous cross‐sectional studies have shown conflicting results regarding the effects of television viewing and occupational sitting on cardiovascular disease ( CVD ) risk factors. The purpose of this study was to compare the association of both television viewing and occupational sitting with CVD events and all‐cause mortality in blacks. Methods and Results Participants included 3592 individuals enrolled in the Jackson Heart Study, a community‐based study of blacks residing in Jackson, Mississippi. Television viewing (4 h/day) and occupational sitting (never/seldom, sometimes, often/always) were self‐reported. Over a median follow‐up of 8.4 years, there were 129 CVD events and 205 deaths. The highest category of television viewing (>4 h/day) was associated with a greater risk for a composite CVD events/all‐cause mortality end point compared with the lowest category (CI , 1.13–1.97). In contrast, the highest category of occupational sitting (often/always) was not associated with risk for a composite CVD events/all‐cause mortality end point compared with the lowest category (never/seldom; hazard ratio, 0.90; 95% CI , 0.69–1.18). Moderate‐to‐vigorous physical activity moderated the association of television viewing with CVD events/all‐cause mortality such that television viewing was not associated with greater risk among those with high moderate‐to‐vigorous physical activity levels. Conclusions Television viewing was associated with greater risk of CVD events and all‐cause mortality, while occupational sitting had no association with these outcomes. These findings suggest that minimizing television viewing may be more effective for reducing CVD and mortality risk in blacks compared with reducing occupational sedentary behavior.

Introduction: The timely evaluation of TIA and minor stroke (TIAMS) is important, but whether TIAMS patients with no debilitating deficits should be admitted or not remains unsettled. We piloted a clinical protocol to assess the feasibility and safety of discharging selected TIAMS patients without disabling deficits from the Emergency Department (ED) to a rapid outpatient stroke clinic: Rapid Access Vascular Evaluation-Neurology (RAVEN). Methods: RAVEN was created as a specialized outpatient neurology clinic for TIAMS patients discharged within 24 hours from the ED at an urban quaternary academic medical center. Patients were first screened in the ED by a neurologist and selected using a decision tool identifying presumed low-risk TIAMS seen in the ED. Criteria included medical (e.g. National Institute of Health Stroke Scale of 5 or less, no disabling deficit, no fluctuating or recurrent symptoms over past month, no thrombolytic agent given, negative CT for hemorrhagic stroke, no new onset atrial fibrillation, blood pressure not over 180/110), as well as social criteria (e.g. patient ability to follow-up within 24 hours). Doppler ultrasound to exclude intracranial and extracranial stenosis, along with neurology re-evaluation was performed as part of RAVEN follow-up. Sample population was evaluated for rates of noncompliance with post-ED follow-up and need for hospitalization from clinic. Final diagnosis was also tabulated. Results: Between December 2016 and June 2018, 162 TIAMS patients seen in the ED were recommended for RAVEN utilizing the decision tool. Of these patients, 153 (94.4%) were evaluated within 24 hours of ED discharge. Two patients (1.3%) who received outpatient evaluation required hospitalization; 101 (66%) of these patients had a final diagnosis of TIAMS. Other common diagnoses included peripheral neuropathy (15%), migraine (12.5%) and seizure/recrudescence (4%). Conclusions: Our pilot data suggests that for a subset of TIAMS patients, rapid outpatient evaluation may be a feasible and safe strategy for TIAMS management. Future work exploring such strategies may improve TIAMS outcomes, reduce ED and inpatient crowding, and offer reductions in healthcare costs associated with TIAMS care.

Introduction: Depression is associated with poor risk factor control after stroke and myocardial infarction (MI). We sought to estimate the prevalence of objectively-measured persistent smoking in stroke and MI survivors in a nationally representative sample, and we hypothesized that depression is associated with persistent smoking. Methods: We performed a cross-sectional analysis using data from 5 cycles of the National Health and Nutrition Examination Survey (2005-2014). Participants in each independent cycle were asked detailed questions about their medical history and underwent neuropsychiatric and laboratory assessment. We included participants 20 years and older who reported a prior stroke or MI and regular tobacco smoking at the time of the event. Individuals who reported both stroke and MI were categorized based on the more recent event. Depression, at the time of survey participation, was defined using a validated threshold ( > 10) on the Patient Health Questionnaire-9 scale. Persistent smoking was defined using validated serum cotinine measures that minimize the effect of second-hand smoke exposure. Multivariable logistic regression methods for survey data were used to assess the association between depression and persistent smoking while adjusting for demographics and smoking-related conditions and behaviors. Results: We identified 1,215 participants with prior stroke or MI who also reported regular tobacco smoking at the time of the event. The mean age was 74.1 years (standard error [SE], 0.5), and the mean duration since the event was 9.7 years (SE, 0.4). Serum cotinine levels revealed evidence of persistent smoking in 429 (41.8%; SE, 1.9%) individuals. Depression was present at the time of survey participation in 30% of persistent smokers versus 13% of former smokers (P Conclusions: In this nationally representative sample, 42% of smokers with stroke or MI had laboratory evidence of persistent smoking several years later. Improved smoking cessation efforts and interventions are needed, especially for those with depression.

Introduction: Patients presenting to emergency departments (ED) with TIA and minor strokes (TIAMS) are often admitted for expedited evaluation, though outpatient care models have been proposed. We piloted a rapid outpatient evaluation protocol for patients presenting with TIAMS within 24 hours of ED discharge. We hypothesized that this approach would reduce hospital costs and length of stay (LOS). Methods: This analysis looked at patients presenting to our institution’s ED with TIAMS (NIHSS < 5) in calendar year 2017. We compared hospitalization LOS, costs and expected revenues between admitted patients and those referred for rapid outpatient evaluation. Patients eligible for outpatient evaluation were without disabling deficits, recurrent symptoms, new-onset atrial fibrillation, prior carotid imaging with >50% stenosis, and not receiving thrombolysis. Disabling deficits were defined as new gait impairments, significant motor weakness, hemianopia, dysphagia or severe aphasia. Cost data was obtained from our finance department and expected revenue was estimated using Medicare reimbursement data, assuming Medicare-Fee for Service as the primary payer for all patients. Results: We identified 92 patients referred to our rapid outpatient clinic and 90 admitted patients (mean NIHSS 0.8 vs 1.8 respectively). In comparison to patients who were admitted, patients referred to outpatient evaluation had shorter hospital stays, lower total hospitalization costs, and decreased net-losses after accounting for expected revenue (Table). Only one patient in the outpatient cohort was readmitted for further management. Overall, the one-year pilot cohort averted approximately 138 bed-days and $950,000 in hospitalization costs. Conclusions: For patients who presented to our ED with TIAMS without disabling deficits, rapid outpatient evaluation reduced hospital LOS and total costs. Further research is needed to incorporate costs to payers and patients.

Background and Purpose: Idiopathic moyamoya syndrome (IMMS) is a progressive narrowing of the anterior circulation arteries resulting in the development of a tenuous collateral blood supply which is prone to rupture or thrombosis. IMMS has mostly been studied in East Asian populations where it was first described, with limited data describing this syndrome in non-Asians. We aimed to describe IMMS patients in New York and identify differences between Asians and non-Asians in this population. Methods: Using the New York State Department of Health Statewide Planning and Research Cooperative System database from 2000-2014 we identified all newly diagnosed cases of IMMS (ICD-9 437.5) in adults aged 18 and older. We excluded patients with down syndrome, neurofibromatosis type 1 and sickle cell disease. We compared patient demographics, comorbidities and extracranial-intracranial revascularization (ECIC) rates for IMMS patients that self-identified with Asian race/ethnicity vs those who did not. Results: All IMMS diagnoses occurred in urban hospitals. There were 554 IMMS patients in total; 89.4% (n=495) were non-Asian while only 10.6% (n=59) were Asian. A smaller proportion of non-Asian IMMS patients were diagnosed in smaller, non-academic hospitals compared to Asians (3.8% vs 10.2%, p=0.03) (Table). Both groups showed comparable rates of characteristics and comorbidities. Stroke risks following IMMS diagnosis were similar for both Asians and non-Asians (13.6% vs 22.4%, p=0.1); strokes occurred later for non-Asian patients with ECIC than in those without (2.1 + 2.8 vs 1.4 + 2.1 years, p=0.04). No subsequent strokes occurred in Asians after ECIC. Conclusion: Individuals of non-Asian origin account for almost 90% of IMMS diagnoses in New York State, but they are infrequently diagnosed in small, non-academic hospitals. Further research is needed to identify a distinctive phenotype and genotypic profile of IMMS in non-Asians.

Introduction: Understanding patient preferences may help guide decision making around discharge timing after TIA or minor stroke (TIAMS) and may lead to treatment algorithms with higher patient satisfaction and adherence. Psychological stress, particularly a sense of helplessness and vulnerability (defined as “threat perception”) may be associated with adverse psychological outcomes following TIAMS, including the development of post-traumatic stress. We hypothesized that TIAMS patients with higher threat perception would be more likely to prefer inpatient care over early emergency department (ED) discharge. Methods: We analyzed ED patients in a large urban academic medical center with suspected TIAMS (defined as National Institutes of Health Stroke Scale (NIHSS) score of ≤5). Patients reported discharge preferences and completed a validated 7 item self-report scale of threat perception (e.g. “I am worried I am going to die. I feel helpless”). Results: 302 suspected TIAMS patients were evaluated (mean age: 63.7±15.1, 52% female, 24.8% Black, 48% Hispanic, median NIHSS= 2). 217 patients (70.7%) preferred hospital admission compared to ED discharge. In unadjusted analysis, those who preferred admission had similar ED threat scores compared to those who preferred early discharge (8.1 ±5.2 vs 7.2±4.8; p=0.24). In the adjusted model, threat perceptions remained unassociated with discharge preference, however, women and Hispanics were more likely to prefer inpatient admission (Table 1) Conclusion: Overall, TIAMS patients preferred inpatient admission over early discharge. Discharge preference was not associated with higher threat perception. Further research examining potential drivers of patient preferences may inform patient discussions and optimize patient satisfaction with rapid outpatient TIAMS care.

Introduction: Recent studies demonstrated the efficacy and safety of pharmacological smoking cessation therapy for patients with heart disease. Similar data are lacking for patients with cerebrovascular disease, who pose unique safety concerns such as seizure and neuropsychiatric risks. We systematically reviewed the evidence for the efficacy and safety of pharmacological cessation therapies in patients with cerebrovascular disease. Methods: We searched the Medline, Cochrane, and Clinicaltrials.gov databases to identify randomized controlled trials (RCT) and observational studies comparing varenicline, bupropion, or nicotine replacement therapy (NRT) versus non-pharmacological cessation therapies in patients with ischemic and hemorrhagic stroke. We included studies that reported rates of smoking cessation, worsening or recurrent cerebrovascular disease, seizures, or neuropsychiatric events. The quality of evidence was assessed using a structured framework. We adhered to systematic review guidelines. Results: We identified 2 RCTs and 6 observational studies; 3 included ischemic stroke and transient ischemic attack, 2 subarachnoid hemorrhage (SAH), and 3 did not specify. There was substantial heterogeneity of the timing and nature of interventions, precluding meta-analysis. Pharmacological therapies were often co-administered with intensive behavioral interventions. Efficacy was assessed in 4 studies; cessation rates ranged from 33% to 66% with pharmacological therapy versus 15% to 47% without. Results were not statistically significant in any individual study. Safety data in ischemic stroke were scarce. Among patients with SAH, patients who received NRT in 1 study had a higher incidence of seizures (9% vs 2%; P=0.024) and delirium (19% vs 7%; P=0.006), but rates of vasospasm were not statistically different in 3 studies. Conclusions: There were insufficient high-quality data to conclusively assess the efficacy and safety of pharmacological smoking cessation therapies in patients with cerebrovascular disease. Combined with behavioral interventions, these therapies resulted in numerically higher cessation rates. The safety of these agents, particularly with respect to seizures and delirium, warrants further study.

Background: Pregnancy is associated with increased stroke risk in young women. Idiopathic moyamoya syndrome (IMMS) is a rare condition characterized by progressive narrowing of large cerebral arteries resulting in flimsy collaterals prone to rupture or thrombosis. Data are limited on pregnancy outcomes in women with IMMS. We hypothesized that IMMS would be associated with increased pregnancy morbidity, including stroke. Methods: Using the New York State Department of Health Statewide Planning and Research Cooperative System data from 2000-2014 we identified all women aged 18 and older with diagnoses of IMMS (ICD-9 437.5) who had hospitalizations for delivery at any time either prior, concomitant or subsequent to IMMS diagnosis. We considered a pregnancy to be IMMS-exposed if it occurred ≤ 3 years prior to, or any time after, IMMS diagnosis. We defined pregnancy morbidity as admission within 1 year of delivery for any of the Center for Disease Control and Prevention’s severe maternal morbidity indicators, including stroke. We compared the morbidity of IMMS-exposed pregnancies to unexposed pregnancies occurring in the same cohort >3 years prior to IMMS diagnosis. We used conditional logistic regression to calculate odds ratio (OR) and 95% confidence intervals (95%CI), adjusting for women with both exposed and unexposed pregnancies. Results: We identified 134 patients with IMMS, with 117 exposed pregnancies and 147 unexposed pregnancies. Severe maternal morbidity was higher for exposed pregnancies (33.3% vs 19.0%, OR: 2.1, 95%CI: 1.2-3.7). After adjusting for maternal morbidity, exposed pregnancies had more caesarean sections (44.4% vs 23.0%, OR: 4.2, 95%CI: 2.3-7.6). Complications occurring during and after exposed pregnancies included stroke, acute myocardial infarction, cardiac arrest, cardiac arrhythmia requiring conversion, eclampsia, pulmonary edema, and adult respiratory distress syndrome. Conclusion: Pregnancies within 3 years prior or any time after IMMS diagnosis had increased maternal morbidity within 1 year of delivery. Prospective studies are needed to better characterize increased maternal risks for women with moyamoya syndrome and develop preventive strategies.

Introduction: Diabetes mellitus has deleterious effects on blood vessel integrity via several mechanisms including blood brain barrier injury, excitatory chemokines, acidosis, and edema. It has been associated with symptomatic intracerebral hemorrhage (sICH) after alteplase administration for ischemic stroke. We aim to determine the association between diabetes and sICH in patients undergoing thrombectomy. Methods: Data was abstracted from the Rhode Island Hospital prospective stroke registry and included consecutive patients who were selected for thrombectomy at our institution over a period of 24 months with the goal of identifying risk factors for sICH. The primary predictor was history of diabetes and the primary outcome was sICH defined based on the modified SITS-MOST criteria (parenchymal hematoma along with increase in NIHSS by 4 points or more). We compared baseline characteristics between patients with and without sICH using univariate and multivariable analyses. Statistical analysis was performed using SPSS version 20.0 and a p value of Results: Out of 307 patients, 12 (3.9%) experienced sICH. The mean age was 73 years; 49.2% were men. On univariate analyses, diabetes mellitus was associated with sICH (50.0% vs. 17.3%, p= 0.012). This association persisted on multivariable models adjusting for age, NIHSS score, ASPECTS score, time to reperfusion, and TICI score (Odds Ratio 6.0, 95% CI 1.5-23.3, p=0.011). We performed sensitivity analyses excluding patients who received intravenous tPA (n = 189) and the results remained unchanged (OR 8.5, 95% CI 0.84-83.3, p = 0.071). Conclusion: Diabetes mellitus is an independent predictors of sICH in patients with acute ischemic stroke undergoing mechanical thrombectomy, with or without IV tPA. More studies are needed to confirm our findings and to determine blood sugar control in the post-thrombectomy reduces this risk.

Introduction: It is unknown how the clinical characteristics of stroke mimics treated on Mobile Stroke Units (MSUs) compare to confirmed acute strokes treated on these units. Methods: We retrospectively analyzed all patients transported by the NewYork-Presbyterian MSU in New York City from October 2016-May 2018. A vascular neurologist assigned a final diagnosis after comprehensive medical record review. Clinical data were abstracted, including comorbidities, presenting symptoms, stroke severity, acute treatments, and short-term outcomes. We compared characteristics of patients with a stroke mimic diagnosis versus those with acute ischemic or hemorrhagic stroke using targeted minimum loss-based estimation to adjust for demographics, comorbidities, NIH Stroke Scale (NIHSS) score, and intravenous tPA administration. Results: Among 92 suspected stroke patients transported by MSU, 56 (61%) had confirmed acute stroke (77% ischemic, 23% hemorrhagic) and 36 (39%) had a stroke mimic. Mimics consisted of seizure (n=8), metabolic encephalopathy (n=6), somatoform disorders (n=4), and others (n=18). The mean NIHSS score was 8 (SD 7) among mimics versus 11 (SD 8) among confirmed strokes (p=0.14). The top presenting symptoms among mimics were unilateral weakness (n=8), aphasia (n=6), confusion (n=6), and decreased consciousness (n=6). Nine mimics (25%) received tPA and none had hemorrhagic conversion; while 30 (53%) confirmed strokes received tPA and 2 (7%) had hemorrhagic conversion. There was no difference in MSU arrival-to-tPA time between groups (46 vs. 44 minutes, p=0.70). In multivariable analyses, compared to patients with confirmed stroke, mimics had significantly lower NIHSS scores, higher initial blood pressures, and shorter lengths-of-stay. Rates of death and discharge disposition were similar between groups. Conclusions: Among patients transported by a MSU for suspected stroke, two-fifths were stroke mimics. Seizure, metabolic encephalopathy, and somatoform disorders were the most common mimic diagnoses. Patients with stroke mimics had lower NIHSS scores and less often were treated with tPA.

Each chapter listed in the Table of Contents (see next page) is a hyperlink to that chapter. The reader clicks the chapter name to access that chapter. Each chapter listed here is a hyperlink. Click on the chapter name to be taken to that chapter. Each year, the American Heart Association (AHA), in conjunction with the Centers for Disease Control and Prevention, the National Institutes of Health, and other government agencies, brings together in a single document the most up-to-date statistics related to heart disease, stroke, and the cardiovascular risk factors listed in the AHA’s My Life Check - Life’s Simple 7 (Figure1), which include core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure [BP], and glucose control) that contribute to cardiovascular health. The Statistical Update represents …

Background and Purpose: Hospitals are increasingly utilizing 30-day readmission as a quality of care metric. We hypothesize that common infections common during the stroke stay are associated with 30-day readmission (30dRA). Methods: We conducted a weighted analysis of the federally managed 2013 National Readmission Database to assess the relationship between infection during a stroke hospitalization and 30dRA among ischemic stroke survivors. Ischemic stroke, common infections (defined as sepsis, pneumonia (PNA), and urinary tract infection (UTI)), and comorbidities were identified using ICD-9 diagnosis codes, and IV-tPA or intra-arterial therapy were identified using ICD-9 procedure codes. Survey design logistic regression models were fit to estimate crude and adjusted odds ratios (OR) and 95% confidence intervals (CI) for the association between infections and 30d-RA. Results: Of the 402042 ischemic stroke patients, 11.2% (n=45247) were readmitted within 30 days, and ~16% (n=7240) had an infection during their index hospitalization. Patients who had a common stroke infection during their stroke admission had a 36% higher odds of being readmitted than patients without any type of infection (OR 1.36, 95%CI 1.30-1.42; Figure 1). The increased odds of readmission remained after adjusting for confounders (OR 1.16, 95%CI 1.11-1.22; Figure 1). Stratifying by age, patients under 65 who had an infection during their stroke admission had an increased adjusted odds of 30d-RA (OR 1.38, 95%CI 1.28-1.49), than those over 65 (OR 1.11, 95%CI 1.06-1.17). The increased odds of readmission remained for those who had sepsis, PNA and a UTI (Figure 1), even after adjusting for covariates of interest. Conclusions: Using a nationally representative cohort we show that patients who have a common infection during their stroke stay are at increased odds of being readmitted. This presents a unique patients population who may benefit from an earlier post-stroke follow-up.

Background: Preeclampsia (PEC) occurs in 3-8% of all pregnancies and doubles women’s long-term stroke risk. Prospective data are limited regarding the rate at which this risk develops. We hypothesized that history of PEC would increase risk of early stroke (ES), defined as stroke before age 60 without concurrent PEC, in women in the California Teachers Study (CTS), and that the risk would be modified by aspirin or statin use. Methods: CTS participants aged ≤60 years with no prior stroke at time of enrollment in 1995 were included in this analysis. Baseline characteristics and medical and gynecological history were obtained by serial questionnaires. Participants were followed prospectively and stroke outcomes obtained via linkage with California hospital records through 12/31/2012. Poisson regression was used to calculate relative risk of ES incidence, among those with and without history of PEC, in unadjusted and adjusted models. We used stratified analyses to assess risk of ES in women with and without self-reported use of aspirin and/or statins. Results: Of the 60,817 women included in the analysis, 3734 (6.1%) had PEC. Incident ES occurred in 49 (1.3%) women in the PEC group and 430 (0.8%) in the non-PEC group. Risk of ES incidence was greater in women with PEC compared to non-PEC in unadjusted models (RR 1.7, 95%CI 1.3-2.3). Adjusting for age, hypertension, diabetes, migraine, and obesity, RR remained higher in the PEC group (RR 1.4, 95%CI 1.1-1.9). Stratified analyses showed that this risk was mitigated in women taking aspirin or statins (RR 1.3, 95%CI 0.8-2.1), but elevated in those not taking them (RR 1.5, 95%CI 1.02-2.3). Conclusion: Women with prior PEC were 40% more likely than those without PEC to develop ES, even controlling for other risk factors. Women with a history of PEC should be considered high risk for ES. Randomized trials are needed to assess whether long-term use of aspirin and/or statins would benefit all women with a history of PEC.

Importance: Large vessel disease (LVD) stroke subtype carries the highest risk of early recurrent stroke, reaching up to 30% in the first few days. Predictors of early recurrence have been previously described, but less is known regarding infarct expansion and other causes of neurological worsening. We aim to determine the association between impaired perfusion and neurological decline in patients with LVD subtype. Methods: This is a single center retrospective cohort study of all consecutive patients 18 years or older with LVD admitted with a diagnosis of ischemic stroke within 24 hours from symptom onset (12/1/2016 to 3/31/2017). Patients with 1) evidence of ≥ 50% stenosis of a large intra- or extracranial artery on computerized tomography angiography (CTA); 2) symptoms referable to the territory of the affected artery and NIHSS < 15 and 3) perfusion imaging data using the RAPID processing software were included. The primary predictor was unfavorable mismatch volume ≥15 mL, defined as perfusion deficit of Tmax > 6sec volume minus infarct volume similar to neuro-interventional trials. The outcome was recurrent cerebrovascular events (RCVE) at 90 days (adjudicated independently by two vascular neurologists) defined as a decline in neurologic function in the absence of a medical cause, or new infarct or infarct extension in the territory of the affected artery. We estimated the hazard ratio (HR) and 95% confidence interval (CI) for unfavorable perfusion imaging as predictor of RCVE using univariable and multivariable Cox proportional hazards models. Results: Sixty-eight patients met our inclusion criteria (mean age 64.7 years; 61.8% male; 58.8% intracranial LVD). When compared to patients without RCVE, patients with RCVE were more likely to have unfavorable mismatch volume [71.4% vs. 14.8%, p Conclusion: Perfusion mismatch is associated with RCVE in patients with ischemic stroke due to LVD. Pursuit of more aggressive treatment and management strategies may be warranted in this population.

Background and Purpose: We hypothesized that acute ischemic stroke (AIS) patients with hospital acquired infection (HAI) would have worse outcomes than patients with an infection present on admission (IPOA) or no infection. Methods: We used the 2007-2009 California State Inpatient Database from the Health Care Utilization Project (HCUP). Patients who were over the age of 18 and hospitalized with AIS, defined by previously validated ICD-9 codes, were included. Validated ICD-9 codes for sepsis, pneumonia and urinary tract infections were used to categorize patients as having IPOA (infection diagnosed within 24 hours of admission), HAI (infection during admission), or no infection using federal guidelines. The outcomes of interest were length of hospital stay (LOS), and poor discharge outcome (discharge someplace other than home). Results: A total of 133,678 patients with diagnosis of AIS were identified; 2.6% (N=3436) had HAI, 15.1% (N=20126) had IPOA, and 82.3% (N=110026) had no infection. Mean LOS was longer for patients with HAI compared to IPOA and no infection (18.5 vs. 8.5 vs. 5.1 days: p Conclusion: IPOA and HAI were each associated with increased LOS. Even after accounting for LOS, patients with HAI had poor discharge outcomes and a higher risk of death.

Background and Purpose: We sought to determine when transporting patients directly to a comprehensive stroke center (CSC; the “mothership”) is favorable compared to a “drip-and-ship” approach while accounting for the varying predictive abilities of pre-hospital large vessel occlusion (LVO) screening methods. Methods: We built a decision analysis model to compare anticipated functional outcomes for patients who are within IV-tPA treatment window in “mothership” and “drip-and-ship”. Key branches included IV-tPA eligibility, IV-tPA only or endovascular therapy (ET), successful reperfusion after ET, and treatment effects. In terms of the probability of requiring ET, we assessed three pre-hospital LVO screening methods: no LVO screening, the Rapid Arterial oCclusion Evaluation (RACE) Scale for Stroke, and in-ambulance CT angiography for LVO. Good outcome was defined as mRS 0-1 and, secondarily, mRS 0-2. Imputed probabilities and workflow times were extracted from published studies. We used one-way and two-way sensitivity analyses to vary two key inputs: time from onset to arrival at primary stroke center (PSC) and additional travel time to CSC. Results: The relative benefit of the “mothership” approach varied with the likelihood of pre-hospital LVO identification for outcome of mRS 0-1. In the absence of pre-hospital LVO screening, “drip-and-ship” was always favored. When pre-hospital CT angiography is used, “mothership” is always favored. When modeling the use of the RACE Scale for patients with onset-to-PSC arrival time less than 70 minutes, “mothership” was favored if the additional travel time to CSC was less than 21 minutes. When onset-to-PSC arrival time passed 70 minutes, “mothership” was favored for additional travel times up to 48 minutes (Figure). Conclusion: The results of our decision analysis model suggest that, in addition to transport times, pre-hospital LVO screening and time from stroke onset could influence triage decision making.

Author(s): Mozaffarian, Dariush; Benjamin, Emelia J; Go, Alan S; Arnett, Donna K; Blaha, Michael J; Cushman, Mary; de Ferranti, Sarah; Despres, Jean-Pierre; Fullerton, Heather J; Howard, Virginia J; Huffman, Mark D; Judd, Suzanne E; Kissela, Brett M; Lackland, Daniel T; Lichtman, Judith H; Lisabeth, Lynda D; Liu, Simin; Mackey, Rachel H; Matchar, David B; McGuire, Darren K; III, Mohler Emile R; Moy, Claudia S; Muntner, Paul; Mussolino, Michael E; Nasir, Khurram; Neumar, Robert W; Nichol, Graham; Palaniappan, Latha; Pandey, Dilip K; Reeves, Mathew J; Rodriguez, Carlos J; Sorlie, Paul D; Stein, Joel; Towfighi, Amytis; Turan, Tanya N; Virani, Salim S; Willey, Joshua Z; Woo, Daniel; Yeh, Robert W; Turner, Melanie B; Comm, Amer Heart Assoc Stat; Subcomm, Stroke Stat

Introduction: Age-related decline in gait and balance is a contributor to morbidity in the elderly. Subclinical cerebrovascular disease, seen on magnetic resonance imaging (MRI) as white matter hyperintensities (WMH) and silent brain infarcts (SBI), is associated with impaired mobility. Less is known about the association of WMH in specific brain regions and mobility impairment. We hypothesized that anterior WMH volume would be associated with lower scores on the Short Physical Performance Battery (SPPB), a well-validated mobility scale associated with falls and mortality in the elderly. Methods: Participants in the Northern Manhattan Study MRI cohort had the SPPB measured a median of 5 years after enrollment. The SPPB has three domains with a maximum total score of 12: gait speed, chair stands, standing balance. Volumetric distributions for WMH volume across 14 brain regions (brainstem, cerebellum, and bilateral frontal, occipital, temporal, and parietal lobes, and bilateral anterior and posterior periventricular white matter) were determined separately for each hemisphere by combining bimodal image intensity distribution and atlas based methods. Multi-variable linear regression was performed to examine the association between SBI and total and regional (frontal, parietal, occipital, temporal, anterior, posterior, and brainstem) head size-corrected WMH volumes, with the total SPPB score; models were adjusted for cardiovascular disease risk factors, osteo-arthritis, and grip strength. Results: Among 668 stroke-free participants with the SPPB available, mean age at the time of assessment was 74 ±9 years, 37% were male and 70% Hispanic; the mean SPPB score was 8.2 ± 2.9, interquartile range 7-10. Mean total WMHV was 0.55±0.75cc, mean anterior WMH volume 0.18±0.24cc, and 12% of participants had SBI. In multi-variable models, total WMHV was associated with a lower SPPB (beta = -0.3 per SD of logWMH, p=0.004), while SBI was not (beta= -0.12, p=0.7). For regional WMH volumes, only greater anterior periventricular WMHV was associated with SPPB (beta= -0.29 per SD, p=0.009). Conclusions: White matter hyperintensities, especially in the anterior cerebral regions, are associated with a lower SPPB. Prevention of subclinical cerebrovascular disease is a potential target to prevent physical aging in the elderly.

Introduction: Leisure time physical activity (LTPA) has been consistently associated with a lower risk of stroke across several populations. Less is known however about how changes over the life-time in physical activity may influence the risk of stroke. We examined the association of changes in engaging in moderate and strenuous physical activity with risk of stroke in the California Teachers Study. Methods: The California Teachers Study is a prospective cohort study established in 1995. Baseline LTPA was obtained using a questionnaire outlining time spent in moderate (brisk walking for example) and strenuous (swimming and running for example); the same questionnaire was repeated in 2005-6. We defined the exposure as engaging in any activity for at least 15 minutes per week (any) in the second questionnaire when not engaging in any on the first questionnaire, with the reference being no change or a decline in activity between both. Multi-variable Cox models were constructed to examine the association of the change in LTPA with risk of stroke. Separate models were created for moderate and strenuous activity. Results: There were a total of 61,256 participants with two LTPA questionnaires available separated by 10 years. A total of 3,111 participants increased their level of moderate activity, 11,744 remained active in both, 2,760 declined from the first to the second questionnaire, while 2,508 reported no activity in both. There were 987 (709 ischemic, 221 hemorrhagic, 247 deaths) strokes after the second questionnaires (mean follow up 6.5 years). In multi-variable models increasing any moderate intensity from none from the two questionnaires, versus no change or decline in activity, was associated with a lower risk of all stroke (adjusted HR 0.83, 95% CI 0.72-0.95). We found no associations of changes in strenuous LTPA with risk of stroke (adjusted HR 0.99, 95% CI 0.83-1.17). The associations were statistically significant for ischemic stroke (adjusted HR 0.75, 95% CI 0.64-0.89) but not hemorrhagic stroke (adjusted HR 0.94, 95% CI 0.72-1.25). Conclusion: Improving or maintaining moderate intensity physical activity is associated with a lower risk of stroke, while changes in strenuous activity is not.

Background: Pregnancy-associated hemorrhagic stroke (HS), while rare, is a significant cause of maternal mortality. Prior studies have suggested that the pathophysiology of HS may differ in pregnant/postpartum women when compared with HS in other young adults. Methods: We conducted a single-center retrospective analysis of a prospectively collected stroke registry, for patients aged 18-45, admitted with HS of any type from 01/2008-03/2015. We reviewed charts for study variables, including patient characteristics, risk factors, stroke mechanisms, and outcomes. Good outcome was defined as modified Rankin score of 0-2 at time of discharge. We compared study variables between three groups: pregnant/postpartum women, non-pregnant/postpartum women, and men. Results: Of 219 young adults with HS during the study period, 93 (42%) were men and 126 (58%) were women, of whom 19 (15.1%) were pregnant/postpartum. Among men, 58 (62.4%) had ICH and 41 (33.3%) had SAH, 31 (75.6%) of which were aneurysmal. Among non-pregnant women, 49 (45.8%) had ICH and 61 (57%) had SAH, 53 (87%) of which were aneurysmal. Among pregnant/postpartum women, 10 had ICH (52.6%) and 11 (57.9%) had SAH, 1 of which was aneurysmal. Compared with men and with non-pregnant women, pregnant/postpartum women had fewer vascular risk factors, were more likely to have history of migraine, and were more likely to have the reversible cerebral vasoconstriction syndrome as stroke mechanism (11/19, 57.9% versus 0/93 men and 2/107 non-pregnant women, p=0.0001). While there were no deaths in the pregnant/postpartum group, there were no significant differences between groups in good outcome (Table). Conclusions: In our analysis, pregnancy-associated hemorrhages were uniquely non-aneurysmal and associated with fewer cerebrovascular risk factors than age-matched men and non-pregnant women, suggesting there is a pregnancy-specific pathophysiology for HS that requires special consideration.

Introduction: Use of emergency medical services (EMS) is associated with decreased door-to-needle time in acute ischemic stroke. While racial and ethnic disparities in EMS use are well documented, the role of patient language in EMS use has been understudied. We sought to characterize EMS use by patient language among IV-tPA treated patients at a single center with a large Spanish-speaking patient population. Methods: We identified all patients who received IV-tPA over five years (7/2011-6/2016) at an academic medical center in New York City. Primary language, EMS use, pre-notification, and patient demographics were recorded from the EMR. We compared baseline characteristics, EMS use, and stroke pre-notification between English and Spanish-speaking patients. Logistic regression was used to measure the association between primary patient language and EMS use, adjusting for potential confounders. Results: Over the study period, 391 patients received IV-tPA; 208 (53%) primarily spoke English and 174 (45%) primarily spoke Spanish. Nine patients (2%) spoke other languages and were excluded. Mean age (66 vs. 69, p=0.09), male sex (43% vs. 33%, p=0.05) and median NIHSS (7 vs. 6, p=0.12) did not differ between English and Spanish-speaking patients. Of the 380 (97%) patients with EMS data, EMS use was higher among Spanish-speaking patients (69% vs. 80%, p Conclusion: Among patients treated with IV-tPA at an urban academic medical center, EMS usage was higher in Spanish-speakers compared to English-speakers. Although language is not an exact surrogate for ethnicity, these findings are in contrast to previously published work demonstrating low rates of EMS usage among Hispanics. Future studies should evaluate differences in EMS utilization according to primary language as well as ethnicity.

Background: Infective endocarditis (IE) affects up to 20,000 people per year in the United States. Stroke is a feared complication of IE and is associated with high morbidity and mortality. We aim to identify predictors of stroke in a large sample of patients treated at a tertiary care center. Methods: A retrospective chart review was carried out using ICD9 codes for IE and cerebrovascular events in patients admitted to the New York Presbyterian Hospital/Columbia University Medical Center from 2000 to 2015. Incident stroke was ascertained if imaging demonstrated an acute infarction during the hospital visit in which endocarditis was diagnosed using Duke’s criteria. Demographics, vascular risks and ancillary data were obtained by chart review. Generalized linear models were used to obtain the risk ratio (RR) and their 95% confidence intervals (95%CI) adjusting for age, sex, ethnicity, hypertension, diabetes, dyslipidemia, smoking, congestive heart failure (CHF), presence of cardiac vegetations, valvular abscesses, positive blood culture, and immunosuppression. Results: The sample included 727 IE subjects (mean age 61±18, range 18-101, 62% men, 62% non-white). Twelve percent of the sample were immunosuppressed. The majority of the patient had vegetations (61%) and positive blood cultures (87%, MRSA 13%) while valvular abscess were less frequent (13%). Of the 727 patients, 13% had an acute pre-surgical stroke (10% ischemic and 3% hemorrhagic). Meanwhile, of the 314 patient who underwent surgical intervention, only 0.5% had post-surgical strokes. The risk of pre-operative ischemic stroke was higher among patients with diabetes (RR 1.7, 1.1-2.8), cardiac vegetations (RR 2.8, 1.6-5.0), and history of prior stroke (RR 1.8, 1.8-2.9) while the risk of pre-surgical hemorrhagic stroke was higher among patients with history of prior stroke (RR 4.5, 1.7-11.9). Conclusions: Prior stroke was a risk factor for ischemic and hemorrhagic stroke, which suggests baseline brain vulnerability that may influence the risk of stroke in the setting of IE. Additionally, diabetes and the presence of vegetations increased the risk of ischemic stroke. Early identification of sub-populations with IE at risk of stroke may help stratify risk and test preventive interventions.

Introduction: Recent evidence suggests that psychological distress, including symptoms of psychiatric illness, may acutely increase the risk of stroke. However, current studies are limited by small sample sizes, inherent recall bias, and poorly defined criteria for what constitutes psychological distress. Methods: We used a case-crossover design, where each patient serves as his/her own control, to assess the relationship between the diagnosis of a psychiatric condition (defined by ICD-9 codes) and stroke (combined hemorrhagic and ischemic events) in adults over the age of 18. Data were utilized from the Healthcare Cost and Utilization Project (HCUP) for the state of California from 2007 - 2009. Cases in which both stroke and psychiatric diagnoses were present on arrival were excluded from the analysis. The relationship between psychiatric hospitalization and stroke was assessed through conditional logistic regression, with separate analyses conducted for 15, 30, 90, 180, and 365-days pre-stroke. Results: A total of 52,068 strokes were identified. Psychiatric conditions diagnosed within 1 year of stroke were found in 3,337 (6.4%) patients. Compared to patients without (n = 48,731), patients with a recent psychiatric hospitalization had a higher proportion of women (59.67% vs. 50.11%) and longer hospital course (8.9 days vs. 6.9). The presence of a psychiatric condition leading to hospitalization was associated with increased odds of stroke within all five pre-defined time periods (Table 1), with the highest odds of stroke occurring in those who most recently experienced a psychiatric visit (15 day OR = 3.48, 95% CI; 2.68-4.52). Conclusions: Psychiatric hospitalization increases the short-term risk of stroke, particularly within the 15-day period following the diagnosis. This risk decreases but persists for at least 1 year.

Background and Purpose: Infections are associated with poor outcomes in young people with ischemic stroke, particularly if they are hospital-acquired. However, the influence of infection on hemorrhagic stroke outcomes in a young population is less well characterized. Methods: We conducted a single-center retrospective analysis of a prospectively collected stroke registry, for patients, aged 18-45, admitted with hemorrhagic stroke of any type from 01/2008 to 03/2015. We reviewed charts for study variables, including patient characteristics, risk factors, and hospital-acquired infections (HAI) or infections present on admission (POA). Poor outcome was defined as modified Rankin score of 3-6 at time of discharge. We compared patients with HAI and infection POA to those without an infection. Results: Of the 219 hemorrhage cases in young adults, 31 (14%) had an infection POA, and 65 (29.7%) had a HAI. As shown in the table, patients who had a HAI and a POA infection had higher baseline NIHSS than those without an infection. In the unadjusted analyses, POA infections (OR = 2. 96, 95%CI: 1.91-4.58) and HAI (OR= 6.51, 95%CI: 4.06 - 10.44) are associated with poor mRS on discharge for hemorrhagic stroke. Adjusting for NIHSS, the relationship between POA infections and poor outcome is no longer significant (OR = 1.45, 95%CI: 0.34- 6.27) while HAI remains associated with poor outcome (OR= 6.73, 95%CI: 2.22 - 20.41). In SAH only patients, after adjusting for NIHSS, HAI remains associated with poor outcome (OR = 21.61, 95%CI: 3.35 - 139) while POA infections are not associated (OR = 3.01, 95%CI: 0.294 - 30.8). In ICH only patients, after adjusting for NIHSS, neither HAI (OR = 3.18, 95%CI: 0.656 - 15.4) nor POA infections (OR = 2.19, 95%CI: 0.334- 14.3) are associated with poor outcomes. Conclusions: In our single-center study, HAI, but not infections POA, were associated with poor outcomes in young adults with SAH. This relationship was not seen in patients with ICH.

Background: In 2012, the American Academy of Neurology (AAN) updated and expanded its ethics curriculum into Practical Ethics in Clinical Neurology, a case-based ethics curriculum for neurologists. Methods: We piloted a case-based bioethics curriculum for neurology residents using the framework and topics recommended by the AAN, matched to clinical cases drawn from Columbia9s neurologic services. Our primary outcome was residents9 ability to analyze and manage ethically complex cases as measured on precurriculum and postcurriculum multiple-choice quizzes. Secondary outcomes included precurriculum and postcurriculum self-assessed comfort in discussing and managing ethically complex cases, as well as attendance at ethics discussion sessions as compared to attendance at other didactic sessions. Results: Resident performance on quizzes improved from 75.8% to 86.7% ( p = 0.02). Comfort in discussing ethically complex cases improved from 6.4 to 7.4 on a 10-point scale ( p = 0.03). Comfort in managing such cases trended toward improvement but did not reach statistical significance. Attendance was significantly better at ethics discussions (73.5%) than at other didactic sessions (61.7%, p = 0.04). Conclusion: Our formal case-based ethics curriculum for neurology residents, based on core topics drawn from the AAN9s published curricula, was successfully piloted. Our study showed a statistically significant improvement in residents9 ability to analyze and manage ethically complex cases as measured by multiple-choice tests and self-assessments.

We read the results of the AATAC trial (Ablation vs Amiodarone for Treatment of Persistent Atrial Fibrillation in Patients with Congestive Heart Failure and an Implanted ICD/CRTD)1 as a stroke neurologist (Dr Willey) and cardiac electrophysiologist (Dr Biviano) with interest. The primary outcomes concerned improvements in heart failure–related symptoms, …

Introduction: The fastest growing segment of the population is those over age 80, in whom there is the highest incidence of stroke. Few clinical trials, however, have targeted this population, and management of risk factors is complicated by higher rates of side effects and polypharmacy. We aimed to characterize whether the risk factors for stroke are different in those age >80 versus Methods: The study sample derives from the Northern Manhattan Study (n=3298), a prospective cohort study among an urban dwelling multi-ethnic population. At enrollment risk factors were assessed by self-report, physical examination, and laboratory data. Leisure-time physical activity (LTPA) was assessed by validated questionnaire and categorized as none versus any. Participants are followed annually for incident stroke which is adjudicated by study neurologists after review of all records and imaging. We fit Cox proportional hazard models to calculate hazard ratios (HR) and 95% confidence intervals (95% CI) for the association of cardiovascular disease risk factors (LTPA, reported alcohol use, fasting HDL-C and LDL-C, history of diabetes, hypertension, heart disease, and tobacco use) with risk of stroke. Multi-variable models also included two-way interaction terms between the primary exposures and age ( Results: The mean age was 69 years and 562 (17%) were age ≥80 years. Physical inactivity was common (41%) and did not differ by age. Subjects were followed for a median of 14 years, and there were 391 total strokes. We found a statistically significant interaction of age ≥80 on the risk of stroke with physical inactivity (p=0.02), diabetes (p=0.04), hypertension (p=0.005), and LDL-C (p=0.03). In stratified models no LTPA versus any (adjusted HR 1.61, 95%CI 1.06-2.43) was associated with an increased risk of stroke among those age ≥80 but not in those younger; LDL-C, hypertension and diabetes were mainly associated with risk of stroke in those below age 80. Conclusion: Lack of leisure-time physical activity is a potentially modifiable stroke risk factor and was more notable than hypertension, diabetes or dyslipidemia among those older than age 80. Improving activity may reduce the risk of stroke in this segment of the population.

Background: There is growing evidence that an increase in dietary sodium increases morbidity and mortality from cardiovascular disease (CVD) at least in part via an increase in blood pressure (BP). Several researchers have identified an association of higher dietary potassium, seen with increased intake of fruits and vegetables, with lower BP. Moreover, there may be a potential interaction of sodium and potassium on CVD health, such that the relative levels of these variables may be more important than their absolute levels. The goal of this study was to determine the association of dietary sodium to potassium ratio (Na:K) with the risk of stroke and CVD in a multi-ethnic urban dwelling population. Methods: Stroke-free participants from the Northern Manhattan Study, a population-based cohort study of stroke incidence, were followed prospectively to assess incident stroke, myocardial infarction and vascular death. Baseline food-frequency questionnaires were analyzed for Sodium and Potassium intake based on self-reported food consumption using DIETSYS software (Block Dietary Data System: Dietsys+ analysis software, version 59, 1999). We examined the association of Na:K with incident stroke (ischemic and overall) as well as combined vascular events (CVE)(stroke, myocardial infarction and vascular death) using Cox-proportional Hazards models adjusting for age, sex, race/ethnicity, total daily calories, adherence to a Mediterranean-style diet, smoking, physical activity, BMI, diabetes, hypertension, and hypercholesterolemia. Results: 2570 participants had dietary data, (mean age 69 ± 10 years, 64% women, 21% white, 53% Hispanic, 24% black); the mean of the Na:K ratio intake was 1.22 with a standard deviation of 0.43. Over a mean follow-up time of 11.9 years (SD=5.4), 274 participants developed stroke (N=232 ischemic) and 745 had a vascular event overall. In adjusted models the Na:K intake ratio was associated with an increased risk for ischemic Stroke (HR=1.5, 95% CI: 1.2-2.0), all stroke (HR=1.5, 95% CI: 1.2-1.9) and CVE (HR=1.2, 95% CI: 1.0-1.4). These results were unchanged in models adjusting for sociodemographic variables only. Conclusions: Our findings suggest that Na:K intake may be an important predictor of the risk of ischemic stroke and overall CVE.

Background: Slower gait speed is associated with adverse outcomes of aging, such as falls and mortality. We hypothesized that physical inactivity, which is prevalent in the elderly, is a major risk factor for slowed gait speed independent of white matter hyperintensity volume (WMHV) and silent brain infarcts (SBI) on magnetic resonance imaging (MRI). Methods: In the Northern Manhattan MRI sub-study (n = 1290), 702 participants had physical performance measures a mean of 5 years after initial MRI. Assessment of gait speed was via a timed 5 meter walk test, averaged over 3 trials. Physical inactivity was assessed using a validated questionnaire at initial enrollment. Multi-variable linear and logistic regression models were fit to examine the association between physical inactivity and gait speed as a continuous outcome and binary outcome cut off at the lowest quartile. Models were adjusted for sociodemographics, hypertension, diabetes, waist circumference, osteoarthritis, and grip. Further mediation analyses were performed adjusted for WMHV and SBI. Results: The mean age at gait assessment was 74(±8.5) years, 61% women and 70% Hispanic; mean gait speed was 1.0±0.3 meter/second. In multi-variable models physical inactivity (54% of cohort), compared to physically activity, was associated with mean 0.04 m/s slower gait speed (p=0.03), and a greater odds of gait speed Conclusion: Physical inactivity is associated with slower gait speed independently of osteoarthritis, markers of sarcopenia, and subclinical ischemic brain injury. Modifying sedentary behavior poses a target for interventions aimed at reducing physical aging.

Intro: While thrombolysis in stroke mimics (SM) is considered safe, recent data highlights the excess cost associated with treatment of these patients. Several studies have identified common demographic features of SM, however less is known about whether language barriers between patient and physician influence SM treatment rates. We sought to evaluate the role of physician-patient language discordance on the rate of SM treatment at a single center serving a large Spanish-speaking population. Hypothesis: Stroke mimic treatment rates are higher when there are language barriers between physician and patient due to greater diagnostic uncertainty Methods: We reviewed the electronic medical record (EMR) for all patients who received tPA in the ED from 7/2011 to 7/2015. Patient’s primary language was obtained from the EMR; language fluency of treating neurologists was obtained via questionnaire; final diagnosis (SM, imaging negative, imaging confirmed) was the attending physician’s impression at discharge. We compared baseline characteristics and SM rates between encounters where the treating neurologist and patient spoke the same language (concordant group) versus those where they did not (discordant group). Means were compared via t test, medians via Mann Whitney U test and dichotomized variables via chi square test. Results: During this period 311 patients received tPA. English was the primary language for 158 (51%), Spanish for 144 (46%), and other languages for 9 (3%); 183 (59%) encounters were classified as concordant and 128 (41%) as discordant. Final diagnosis was SM for 37 (12%); among those with a final diagnosis of stroke, 65 (24%) were imaging negative. There were no significant differences in mean age (67 vs. 70, p=0.1), male sex (38% vs. 32%, p=0.3), and median NIHSS (7 vs. 7, p=0.4) between concordant and discordant groups. We found higher rates of SM in the concordant group (16% vs. 6%, p=0.01). When imaging negative strokes were included with SM, these differences were no longer significant (33% vs. 32%, p=0.9). Conclusion: At our institution, language discordancy does not contribute to higher rates of SM treatment. Careful observation of how language discordant pairs communicate is needed to understand the role of interpreters in these findings

Introduction: Infection has been described as a trigger for acute ischemic stroke, but the relationship between postoperative infection and the risk of postoperative stroke is unclear. We investigated the association between postoperative infection and stroke using the American College of Surgeons National Surgical Quality Initiative Program (NSQIP) database. Hypothesis: Postoperative infection is associated with an increased risk of postoperative stroke. Methods: We used the NSQIP database to identify all patients who underwent surgery between the years of 2000 and 2010 and developed a postoperative stroke within 30 days of surgery. The group was further stratified according to the presence of infection preceding stroke. Using a logistic regression model adjusted for age, race, sex, medical comorbidities, surgical type, and dichotomized functional status, we compared the risk of stroke in patients with and without preceding infections, and investigated the risk of infection following stroke. Results: 729,886 surgical patients were identified, of whom 2,703 (0.3%) developed postoperative stroke. 848 (0.12%) patients developed both postoperative stroke and infection. Among patients who had postoperative stroke, 100 (3.7%) had developed an infection prior to developing a stroke. Patients with infection prior to stroke had a lower risk of stroke than patients who did not develop infection prior to stroke (adjusted odds ratio [OR] 0.25, 95%CI 0.20-0.32). 748 patients (0.1%) developed an infection after having a postoperative stroke. These patients had a higher risk of infection (incidence rate ratio 2.76, 95%CI 2.57-2.97) and a higher odds of infection (adjusted odds ratio [OR] 3.47, 95%CI 3.18-3.78) than patients who did not have a stroke. Conclusions: We found that the presence of a preceding infection was associated with a low risk of postoperative stroke in a large surgical inpatient sample. Although the total number of strokes may have been under-reported, these results conflict with other studies that report that infection is a trigger for ischemic stroke. Further analyses using more granular data are needed to investigate the relationship between postoperative infection and the risk of postoperative stroke.

Background: Prior studies have shown a correlation between the National Institutes of Health Stroke Scale (NIHSS) score and infarct volume on diffusion weighted imaging (DWI); however data are limited in patients with minor stroke whose treatment is controversial. Our aim is to determine the association between DWI lesion(s) volume and the (1) total NIHSS score and (2) NIHSS components in a population of patients with minor ischemic stroke. Methods: We included all patients with minor stroke (NIHSS 0-5) who were enrolled in the prospective Stroke Warning Information and Faster Treatment (SWIFT) study. All patients were admitted to the hospital with a final diagnosis of stroke. We calculated lesion(s) volume (cm 3 ) on DWI sequence using Medical Image Processing, Analysis, and Visualization (MIPAV, NIH, Version 7.1.1). Based on the distribution of lesion volume, we summarized the explanatory value into median cm 3 . We used non-parametric tests to study the association between the primary outcome, DWI lesion(s) volume, and the predictors (NIHSS score and its components). Results: 894 patients had a discharge diagnosis of ischemic stroke; 709 underwent MRI and 510 were DWI positive. There was a weak graded relationship between NIHSS score and median DWI lesion volume in cm 3 : (NIHSS 0: 7.1, NIHSS 1: 8.0, NIHSS 2: 17.1, NIHSS 3: 11.6, NIHSS 4: 19.0, NIHSS 5: 23.6). We also noted highly significant relationships between lesion volume and certain NIHSS components. Compared to patients without the deficit, the median lesion volume was significantly higher in patients with neglect (105.6 vs. 12.5,p=0.025), language disorder (34.6 vs. 11.9,p Conclusion: In patients with minor stroke, the nature of the neurological deficit improves prediction of infarct volume when added to the total NIHSS score. This may lead to clinical and therapeutic implications.

Introduction: Pregnancy-associated stroke (PAS) remains among the leading causes of maternal morbidity and mortality. Up to 20% of women with PAS have preeclampsia or eclampsia (PEC). However, PEC is relatively common (∼3.4% of pregnancies), while PAS is rare (∼20 per 100,000 deliveries). It is not clear what risk factors differentiate women with PEC who develop PAS. Hypothesis: Identifying risk factors for stroke in women with PEC could help identify women at highest risk for PAS. Methods: We used the 2008-2012 New York State Department of Health Statewide Planning and Research Cooperative System (SPARCS) inpatient sample database to identify pregnant or postpartum women (APR MDC 14) aged 12-50 with mild to severe preeclampsia (642.4x-642.5x) or eclampsia (642.6x). We compared non-stroke PEC patients (controls) to those with ischemic (ICD-9 433.xx, 434.xx, 436), ICH (ICD-9 431), SAH (ICD-9 430), and non-specified pregnancy-related strokes, including post-partum stroke (ICD-9 671.7, 674.0-674.4). Risk factors included delivery type (C-section vs vaginal), age, multigravida, primary hypercoagulable state, pre-existing diabetes, obesity and migraine. The associations between risk factors and stroke were evaluated using generalized estimating equation logistic regression adjusting for patients’ re-hospitalizations to calculate odds ratios and 95% confidence intervals (OR, 95%CI) for stroke . Results: There were 85 stroke cases and 41,634 PEC controls without stroke. A majority of strokes in PEC patients occurred postpartum (n=76, 89.4%). Stroke patients were more likely to have eclampsia (OR: 24.7, 95%CI: 15.6-39.3) or severe pre-eclampsia (OR: 1.6, 95%CI: 1.0-2.5) compared to non-stroke patients. In multivariable analyses, being multigravida (OR: 1.4, 95%CI 1.3-1.6), primary hypercoagulable state (OR:2.1, 95%CI 1.8-2.4) and migraine (OR 2.3, 95%CI 2.1-2.5) were also risk factors for stroke. Conclusions: Women with eclampsia were at at the highest risk for pregnancy-associated stroke. Several other risk factors for stroke in women with preeclampsia may also help identify women who warrant closer monitoring for neurological symptoms in the peripartum period.

Background: There remains lack of consensus on who among minor stroke or transient ischemic attack (MS-TIA) patients constitutes a high-risk group that may be targeted by clinical trials to improve early recurrence risk. We aimed to determine predictors of early recurrent cerebrovascular endpoints (RCVE) among patients with MS-TIA. Methods: We retrospectively analyzed data from consecutive patients who presented to the emergency room of Columbia University between Jan 1 st 2010 - Dec 31 st 2014, with MS-TIA (NIHSS 0-3) diagnosed by a neurologist and within 12 hours from onset. The outcome (adjudicated by 3 stroke neurologists) was RCVE (neurological deterioration defined as worsening deficits not attributed to fever or other medical condition or recurrent ischemic stroke or TIA within hospitalization). Our primary predictor was large vessel disease (LVD) stroke subtype. Covariates included demographics, stroke risk factors, symptoms, and imaging parameters. We confirmed our findings in an independent cohort of consecutive MS-TIA patients (NIHSS 0-3) evaluated at Tulane University during the same time period. Results: The cohort at Columbia University Medical Center included 505 patients; mean length of hospital stay (LOS) 3.2 days, 31 had RCVE (6.1%). The Tulane cohort consisted of 753 patients (mean LOS 4.5 days), 40 had RCVE (5.3%); RCVE predictors on univariate and multivariate analyses in both cohorts were LVD subtype and to a lesser extent positive neuroimaging (Tables 1 and 2). There was an increase in percentage of patients with RCVE with both predictors combined as compared to separate use. When neither predictor was present, the rate of RCVE was very low (Figure). RCVE was associated with poor discharge outcome (mRS≥2). Conclusion: In patients with MS-TIA, LVD stroke subtype and perhaps positive neuroimaging predict RCVE in two independent cohorts.RCVE was associated with poor functional outcome. Prospective studies are needed to confirm our findings.

Introduction: Post-operative stroke (POS) is associated with vascular and cardiac surgery, but this finding has mainly been reported among populations receiving vascular and cardiac procedures. We investigated the association between type of surgery and risk of POS in a large, generalizable inpatient cohort from the American College of Surgeons National Surgical Quality Initiative Program (NSQIP) database. Hypothesis: Cardiac and vascular procedures are associated with an increased risk of POS. Methods: We identified patients that underwent surgery between the years of 2000 and 2010. Our primary outcome was POS within 30 days of surgery. Using a hierarchical model adjusted for age, race, sex, medical comorbidities and dichotomized functional status, we assessed for clustering between type of surgery and POS. We then determined risk factors for POS while adjusting for clustering. Each surgical type was compared against all other surgical types. Results: We identified 729,886 patients, of whom 2,703 (0.3%) developed POS. In the hierarchical analysis, cardiac surgery (incidence rate ratio (IRR) 6.38, 95%CI 5.37-7.55), vascular surgery (IRR 4.41, 95%CI 4.08-4.76), and neurosurgery (IRR 2.05, 95%CI 1.69-2.48) were associated with increased risk of POS. The only patient-level factor associated with surgery type was poor preoperative functional status. Accounting for clustering, patients with poor pre-operative functional status (OR 4.11, 95%CI 3.60-4.69), history of stroke (OR 2.35 95%CI 2.06-2.69), history of transient ischemic attack (OR 2.49 95%CI 2.19-2.83), active smoking (OR 1.20, 95%CI 1.08-1.32), and COPD (OR 1.39 95%CI 1.21-1.59) were at higher risk of POS. There was no interaction between preoperative functional status and type of surgery. Conclusions: In a large cohort of surgical inpatients, we found that the risk of POS was significantly associated with cardiac, vascular, and neurosurgical procedures. Certain patient populations, such as those with a dependent pre-operative functional status, may be at a higher risk of POS and may be more likely to undergo cardiac, vascular, or neurosurgical procedures. Further studies are needed to elucidate the relationship between pre-surgical functional status and type of surgery.

Intro: Shorter door-to-needle time (DTN) is associated with better outcomes for ischemic stroke. National increases in tPA volumes are partially driven by treatment of larger numbers of minor strokes. However, it is not known whether treatment times differ in these patients. We sought to evaluate DTN and component times in minor strokes. Hypothesis: In minor strokes DTN is longer due to more diagnostic uncertainty Methods: We reviewed the record of all patients who received tPA in our ED from 7/2011-7/2015. Minor stroke was defined as NIHSS≤5. We compared demographics, EMS usage, pre-notification rates and DTN between minor strokes and all others. We also compared DTN component times, specifically neurologist-dependent times where diagnostic uncertainty may be apparent (stroke activation (SA)-to-tPA and imaging-to-tPA) and ED-dependent times which capture initial stroke recognition (door-to-SA and door-to-imaging). Means were compared via t test, medians via Mann Whitney U test, and dichotomous variables via chi square test. Results: Over this period 311 patients received tPA; 126 (41%) were minor strokes. There were no significant differences in language (48 vs 52% English-speaking, p=0.6) or sex (39 vs 34% male, p=0.3) for minor strokes compared to all others. Minor strokes were younger (62 vs 73 years, p We found longer DTN (61 vs 55 min, p=0.01) in minor strokes compared to all others. For DTN components, door-to-SA (5 vs 2 min, p Conclusion: We found longer DTN in minor strokes. The difference in door-to-stroke activation and door-to-imaging but not other component times suggests delayed recognition of minor strokes at ED presentation. Similarly, less frequent pre-notification points to poor recognition by EMS. Efforts are needed to improve minor stroke recognition by EMS and ED providers

Introduction: Stroke is a rare but feared complication of pregnancy and the postpartum period. Prior studies have found that older age is associated with increased risk of pregnancy-associated stroke (PAS). It is unclear to what extent pregnancy contributes to this increased risk of PAS. There is limited information on age-specific incidence ratios to assess whether the risk of PAS is comparable to stroke in similarly aged non-pregnant women. Hypothesis: Increased incidence of PAS in older women is attributable to the increasing risk of stroke with age. Methods: We used the 2008-2012 New York State Department of Health (NYS DOH) Statewide Planning and Research Cooperative System (SPARCS) inpatient database to identify women aged 12-50 with ischemic (ICD-9 433, 434, 436), ICH (ICD-9 431), SAH (ICD-9 430), and non-specified PAS, including post-partum stroke (ICD-9 671.7, 674). Population data were obtained from NYS DOH Vital Statistics. Age-specific incidence ratios were calculated for strokes in pregnant or postpartum women compared to non-pregnant women. We used standard age groups considered by obstetricians to be at low, moderate, or high risk for pregnancy complications, including stroke. Results: Of 7099 stroke hospitalizations occurring in women, 386 were in pregnant women. The table shows the incidence of stroke in women stratified by pregnancy status and age group, and age-specific incidence risk ratios associated with pregnancy. Conclusions: Compared to non-pregnant women of the same age, pregnant women appeared to be at similarly increased risk of stroke at all ages, except for those over age 40. These results suggest that pregnancy itself does not further increase the risk of stroke in older women, though they could also reflect a tendency for healthier women to have pregnancies at later ages. More research is needed to investigate the characteristics that may put younger women at increased risk of stroke, compared to their non-pregnant contemporaries.

Background and Purpose— Few studies have addressed outcomes among patients ≥80 years treated with acute stroke therapy. In this study, we outline in-hospital outcomes in (1) patients ≥80 years compared with their younger counterparts; and (2) those over >80 years receiving intra-arterial therapy (IAT) compared with those treated with intravenous recombinant tissue-type plasminogen activator (IV rtPA). Methods— Stroke centers within the Specialized Program of Translational Research in Acute Stroke (SPOTRIAS) prospectively collected data on all patients treated with IV rtPA or IAT from January 1, 2005, to December 31, 2010. IAT was defined as receiving any endovascular therapy; IAT was further divided into bridging therapy when the patient received both IAT and IV rtPA and endovascular therapy alone. In-hospital mortality was compared in (1) all patients aged ≥80 years versus younger counterparts; and (2) IAT, bridging therapy, and endovascular therapy alone versus IV rtPA only among those age ≥80 years using multivariable logistic regression. An age-stratified analysis was also performed. Results— A total of 3768 patients were included in the study; 3378 were treated with IV rtPA alone and 808 with IAT (383 with endovascular therapy alone and 425 with bridging therapy). Patients ≥80 years (n=1182) had a higher risk of in-hospital mortality compared with younger counterparts regardless of treatment modality (OR, 2.13; 95% CI, 1.60–2.84). When limited to those aged ≥80 years, IAT (OR, 0.95; 95% CI, 0.60–1.49), bridging therapy (OR, 0.82; 95% CI, 0.47–1.45), or endovascular therapy alone (OR, 1.15; 95% CI, 0.64–2.08) versus IV rtPA were not associated with increased in-hospital mortality. Conclusions— IAT does not appear to increase the risk of in-hospital mortality among those aged >80 years compared with IV thrombolysis alone.

Objective: To examine the independent association between physical activity and subclinical cerebrovascular disease as measured by silent brain infarcts (SBI) and white matter hyperintensity volume (WMHV). Methods: The Northern Manhattan Study (NOMAS) is a population-based prospective cohort examining risk factors for incident vascular disease, and a subsample underwent brain MRI. Our primary outcomes were SBI and WMHV. Baseline measures of leisure-time physical activity were collected in person. Physical activity was categorized by quartiles of the metabolic equivalent (MET) score. We used logistic regression models to examine the associations between physical activity and SBI, and linear regression to examine the association with WMHV. Results: There were 1,238 clinically stroke-free participants (mean age 70 ± 9 years) of whom 60% were women, 65% were Hispanic, and 43% reported no physical activity. A total of 197 (16%) participants had SBI. In fully adjusted models, compared to those who did not engage in physical activity, those in the upper quartile of MET scores were almost half as likely to have SBI (adjusted odds ratio 0.6, 95% confidence interval 0.4–0.9). Physical activity was not associated with WMHV. Conclusions: Increased levels of physical activity were associated with a lower risk of SBI but not WMHV. Engaging in moderate to heavy physical activities may be an important component of prevention strategies aimed at reducing subclinical brain infarcts.

Background and Purpose— Depression is highly prevalent after stroke and may influence recovery. We aimed to determine whether depressed mood acutely after stroke predicts subsequent disability and mortality. Methods— As part of the Northern Manhattan Stroke Study, a population-based incident stroke case follow-up study performed in a multiethnic urban population, participants were asked about depressed mood within 7 to 10 days after stroke. Participants were followed every 6 months the first 2 years and yearly thereafter for 5 years for death and disability measured by the Barthel Index. We fitted polytomous logistic regression models using a canonical link to examine the association between depressed mood after stroke and disability comparing moderate (Barthel Index 60 to 95) and severe (Barthel Index Results— A question about depressed mood within 7 to 10 days after stroke was asked in 340 of 655 patients with ischemic stroke enrolled, and 139 reported that they felt depressed. In multivariate analyses controlling for sociodemographic factors, stroke severity, and medical conditions, depressed mood was associated with a greater odds of severe disability compared with no disability at 1 (OR 2.91, 95% CI 1.07 to 7.91) and 2 years (OR 3.72, 95% CI 1.29 to 10.71) after stroke. Depressed mood was not associated with all-cause mortality or vascular death. Conclusion— Depressed mood after stroke is associated with disability but not mortality after stroke. Early screening and intervention for mood disorders after stroke may improve outcomes and requires further research.

Objective To identify the frequency of and impact on outcome of generalized convulsive status epilepticus (GCSE) among patients with nontraumatic subarachnoid hemorrhage (SAH). Methods We used the Nationwide Inpatient Sample, a database of admissions to nonfederal United States hospitals between 1994 and 2002, for this study. From this database, we identified all adult patients with nontraumatic SAH who were admitted through the emergency department. Independent predictors of GCSE and mortality were identified using multivariate logistic regression. Multivariate linear regression analysis was used to determine whether GCSE was independently associated with increased cost and/or duration of hospitalization. Results Among the 29,998 patients hospitalized with nontraumatic SAH, GCSE was reported to occur in 0.2% of patients (N = 73 patients). GCSE occurred more frequently among those in the youngest tertiale (49 years old or younger; odds ratio, 3.2; 95% confidence interval, 2.0-5.1), those with renal disease (odds ratio, 4.8; 95% confidence interval, 2.6-8.8), and those who did not undergo a neurosurgical procedure involving a craniotomy (odds ratio, 2.2; 95% confidence interval, 1.3-3.8). GCSE was independently associated with higher in-hospital mortality (48% versus 33% of patients; odds ratio, 2.1; 95% confidence interval, 1.3-3.4; P = 0.002) and longer (9 versus 7 days; P = 0.016) and more expensive (US $39,677 versus US $26,686; P = 0.007) hospitalizations. Conclusion GCSE rarely complicates SAH; however, it is associated with increased patient mortality, length of hospital stay, and cost. GCSE occurs more frequently in young patients, those with a history of renal disease, and patients who do not undergo a craniotomy.