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Background: Cerebral small vessel disease (cSVD) is a major cause of stroke and dementia. Previous studies on the prevalence of cSVD are mostly based on single geographically defined cohorts in high-income countries. Studies investigating the prevalence of cSVD in low- and middle-income countries (LMICs) are expanding but have not been systematically assessed. Aim: This study aims to systematically review the prevalence of cSVD in LMICs. Results: Articles were searched from the Ovid MEDLINE and EMBASE databases from 1 January 2000 to 31 March 2022, without language restrictions. Title/abstract screening, full-text review, and data extraction were performed by two to seven independent reviewers. The prevalence of cSVD and study sample size were extracted by pre-defined world regions and health status. The Risk of Bias for Non-randomized Studies tool was used. The protocol was registered on PROSPERO (CRD42022311133). A meta-analysis of proportion was performed to assess the prevalence of different magnetic resonance imaging markers of cSVD, and a meta-regression was performed to investigate associations between cSVD prevalence and type of study, age, and male: female ratio. Of 2743 studies identified, 42 studies spanning 12 global regions were included in the systematic review. Most of the identified studies were from China (n = 23). The median prevalence of moderate-to-severe white matter hyperintensities (WMHs) was 20.5%, 40.5%, and 58.4% in the community, stroke, and dementia groups, respectively. The median prevalence of lacunes was 0.8% and 33.5% in the community and stroke groups. The median prevalence of cerebral microbleeds (CMBs) was 10.7% and 22.4% in the community and stroke groups. The median prevalence of moderate-to-severe perivascular spaces was 25.0% in the community. Meta-regression analyses showed that the weighted median age (51.4 ± 0.0 years old; range: 36.3–80.2) was a significant predictor of the prevalence of moderate-to-severe WMH and lacunes, while the type of study was a significant predictor of the prevalence of CMB. The heterogeneity of studies was high (>95%). Male participants were overrepresented. Conclusions: This systematic review and meta-analysis provide data on cSVD prevalence in LMICs and demonstrated the high prevalence of the condition. cSVD research in LMICs is being published at an increasing rate, especially between 2010 and 2022. More data are particularly needed from Sub-Saharan Africa and Central Europe, Eastern Europe, and Central Asia.

Objective To compare the utility of the Mild Behavioral Impairment-Checklist (MBI-C) and Neuropsychiatric Inventory Questionnaire (NPI-Q) to capture NPS in subjective cognitive decline (SCD), mild cognitive impairment (MCI), and dementia. Methods In this cross-sectional memory clinic study, linear regression models compared MBI-C (n = 474) and NPI-Q (n = 1040) scores in relation to Montreal Cognitive Assessment (MoCA) score. Results MBI prevalence was 37% in subjective cognitive decline, 54% in mild cognitive impairment, and 62% in dementia. Worse diagnostic status was associated with higher MBI-C and NPI-Q score ( P < .001), lower MoCA ( P < .001), and greater age ( P < .001). Higher MBI-C (β −.09; 95% CI −.13, −.05) and NPI-Q (β −.17; 95% CI −.23, −.10) scores were associated with lower MoCA scores, with psychosis most strongly associated (β −1.11; 95% CI −1.56, −.65 vs β −1.14; 95% CI −1.55, −.73). Conclusions The MBI-C captures global and domain-specific NPS across cognitive stages. Both the MBI-C and NPI-Q have utility in characterizing NPS.

Background: The incidence of stroke in developed countries is increasing selectively in young individuals, but whether this is secondary to traditional vascular risk factors is unknown. Methods: We used the Canadian Community Health Survey from 2000 to 2016 to create a large population-representative cohort of individuals over the age of 30 and free from prior stroke. All analyses were stratified by age decile. We linked with administrative databases to determine emergency department visits or hospitalizations for acute stroke until December 2017. We calculated time trends in risk factor prevalence (hypertension, diabetes, obesity, and smoking) using meta-regression. We used Cox proportional hazard models to evaluate the association between vascular risk factors and stroke risk, adjusted for demographic, co-morbid, and social variables. We used competing risk regression to account for deaths and calculated population-attributable fractions. In a sensitivity analysis, we excluded those with prior heart disease or cancer. Results: We included 492,400 people in the analysis with 8865 stroke events over a median follow-up time of 8.3 years. Prevalence of hypertension, diabetes, and obesity increased over time while smoking decreased. Associations of diabetes, hypertension, and obesity with stroke risk were progressively stronger at younger age (adjusted hazard ratio for diabetes was 4.47, 95% confidence interval (CI) = 1.95–10.28 at age 30–39, vs 1.21, 95% CI = 0.93–1.57 at age 80+), although the obesity association was attenuated with adjustment. Smoking was associated with higher risk of stroke without a gradient across age deciles, although had the greatest population-attributable fraction at younger age. The hazard ratio for stroke with multiple concurrent risk factors was much higher at younger age (adjusted hazard ratio for 3–4 risk factors was 8.60, 95% CI = 2.97–24.9 at age 30–39 vs 1.61, 95% CI = 0.88–2.97 at age 80+) and results were consistent when accounting for the competing risk of death and excluding those with prior heart disease or cancer. Conclusions: Diabetes and hypertension were associated with progressively elevated relative risk of stroke in younger individuals and prevalence was increasing over time. The association of obesity with stroke was not significant after adjustment for other factors. Smoking had the greatest prevalence and population-attributable fraction for stroke at younger age. Our findings assist in understanding the relationship between vascular risk factors and stroke across the life span and planning public health measures to lower stroke incidence in the young.

Spontaneous intracerebral hemorrhage is a particularly devastating type of stroke with greater morbidity and mortality compared with ischemic stroke and can account for half or more of all deaths from stroke. The seventh update of the Canadian Stroke Best Practice Recommendations includes a new stand-alone module on intracerebral hemorrhage, with a focus on elements of care that are unique or affect persons disproportionately relative to ischemic stroke. Prior to this edition, intracerebral hemorrhage was included in the Acute Stroke Management module and was limited to its management during the first 12 h. With the growing evidence on intracerebral hemorrhage, a separate module focused on this topic across the care continuum was added. In addition to topics related to initial clinical management, neuroimaging, blood pressure management, and surgical management, new sections have been introduced addressing topics surrounding inpatient complications such as venous thromboembolism, seizure management, and increased intracranial pressure, rehabilitation as well as issues related to secondary management including lifestyle management, maintaining a normal blood pressure and antithrombotic therapy, are addressed. The Canadian Stroke Best Practice Recommendations ( CSBPR) are intended to provide up-to-date evidence-based guidelines for the prevention and management of stroke and to promote optimal recovery and reintegration for people who have experienced stroke, including patients, families, and informal caregivers.

Background: Concern for head injuries is widespread and has been reported by the media to be the number one cause of decreased participation in football among the American youth population. Identifying player mechanisms associated with intentional, or purposeful, head impacts should provide critical data for rule modifications, educational programs, and equipment design. Purpose: To investigate the frequency of intentional and unintentional head impacts and to examine the player mechanisms associated with intentional high-magnitude head impacts by comparing the impact mechanism distributions among session type, player position, and ball possession. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Head impact sensors and video footage of 68 players were used to analyze and classify 1319 high-magnitude impacts recorded over 1 season of youth football. Results: In total, 80% of the high-magnitude head impacts were classified as being caused by intentional use of the head. Head-to-head impact was the primary impact mechanism (n = 868; 82.7%) within the 1050 intentional high-magnitude impacts, with classifiable mechanisms, followed by head-to-body (n = 139; 13.2%), head-to-ground (n = 34; 3.2%), and head-to-equipment (n = 9; 0.9%). Head-to-head impacts also accounted for a greater proportion of impacts during practices (n = 625; 88.9%) than games, for linemen (n = 585; 90.3%) than perimeters and backs, and for ball carriers (n = 72; 79.1%) than tacklers. Conclusion: Overall, the majority of high-magnitude head impacts were intentional and resulted from head-to-head contact. The proportion of head-to-head contact was significantly higher for practices than games, linemen than backs and perimeter players, and ball carriers than tacklers.

Rationale Although mild and rapidly improving stroke symptoms are the most common first stroke presentation, this group has been understudied in acute stroke trials. Observational and retrospective studies suggest residual disability in one third of patients. Aims To elucidate long-term outcomes of patients with mild and rapidly improving stroke, evaluate the predictors of outcome, and examine the association with alteplase treatment. Sample size The initial estimate of 2650 participants to detect a 9% difference in non-disabled 90-day outcomes between alteplase-treated and untreated participants was revised to 2000 after a pre-planned re-estimation based on actual treatment rates. Methods and design Prospective observational study of patients with mild ischemic stroke (NIHSS ≤ 5) or rapidly improving stroke symptoms evaluated within 4.5 h from onset. Outcomes The primary outcome is the proportion of patients with modified Rankin Scale (mRS) ≥ 2 at 90 days; the primary safety outcome is symptomatic hemorrhagic transformation within 36 h among those treated with alteplase. Secondary outcomes include the 90-day Barthel Index, Stroke Impact Scale 16, European Quality of Life scale, mRS at 30 days, and 30- and 90-day mortality. Discussion MaRISS will define outcomes and their predictors and clarify the effects of alteplase in patients with mild and rapidly improving stroke symptoms, providing clinicians with important information to manage this population.

The 2019 update of the Canadian Stroke Best Practice Recommendations (CSBPR) for Mood, Cognition and Fatigue following Stroke is a comprehensive set of evidence-based guidelines addressing three important issues that can negatively impact the lives of people who have had a stroke. These include post-stroke depression and anxiety, vascular cognitive impairment, and post-stroke fatigue. Following stroke, approximately 20% to 50% of all persons may be affected by at least one of these conditions. There may also be overlap between conditions, particularly fatigue and depression. If not recognized and treated in a timely matter, these conditions can lead to worse long-term outcomes. The theme of this edition of the CSBPR is Partnerships and Collaborations, which stresses the importance of integration and coordination across the healthcare system to ensure timely and seamless care to optimize recovery and outcomes. Accordingly, these recommendations place strong emphasis on the importance of timely screening and assessments, and timely and adequate initiation of treatment across care settings. Ideally, when screening is suggestive of a mood or cognition issue, patients and families should be referred for in-depth assessment by healthcare providers with expertise in these areas. As the complexity of patients treated for stroke increases, continuity of care and strong communication among healthcare professionals, and between members of the healthcare team and the patient and their family is an even bigger imperative, as stressed throughout the recommendations, as they are critical elements to ensure smooth transitions from acute care to active rehabilitation and reintegration into their community.

BACKGROUND: There is limited information about non-selective and contemporary data on quality of stroke care and its variation among hospitals at a national level. PATIENTS AND METHODS: We analysed data of the patients admitted to 258 acute stroke care hospitals covering the entire country from the Acute Stroke Quality Assessment Program, which was performed by the Health Insurance Review and Assessment Service from 2008 to 2014 in South Korea. The primary outcome measure was defect-free stroke care (all-or-none), based on six get with the guidelines-stroke performance measures (except venous thromboembolism prophylaxis). RESULTS: Among 43,793 acute stroke patients (mean age, 67 ± 14 years; male, 55%), 31,915 (72.9%) were hospitalised due to ischaemic stroke. At a patient level, defect-free stroke care steadily increased throughout the study period (2008, 80.2% vs. 2014, 92.1%), but there were large disparities among hospitals (mean = 50.7%, SD = 21.7%). Defect-free stroke care was given more frequently in patients being treated in hospitals with 25 or more stroke cases per month (odds ratio [OR] 2.83; 95% confidence interval [CI] 1.69–4.72), delivery of intravenous thrombolysis one or more times per month (OR 2.37; 95% CI 1.44–3.92), or provision of stroke unit care (OR 1.75; 95% CI 1.22–2.52). DISCUSSION: This study shows that the quality of stroke care in Korea is improving over time and is higher in centres with a larger volume of stroke or intravenous thrombolysis cases and providing stroke unit care but hospital disparities exist. CONCLUSION: Reducing large differences in defect-free stroke care among acute stroke care hospitals should be continuously pursued.

Registries are an important platform to which persons with dementia and other cognitive impairments can contribute to research studies. Registries also provide an opportunity for patients to stay informed about current studies. Engaging patients in registry development can increase sustainability of a registry and patient retention in clinical registries. We sought the perspective of persons with dementia and their accompanying family members about their registry participation experiences, barriers and facilitators to participation, and potential avenues for improvement of registry processes such as recruitment, data collection, and knowledge translation. Two semi-structured focus groups with persons with dementia and their family members ( n = 18) were conducted and analyzed using thematic content analysis. Participants were recruited from an existing patient registry made up of patients currently being seen in a dementia assessment clinic. The main themes identified included altruistic motives with regards to registry participation; and access to and privacy of personal health information. As electronic health records are becoming more common, understanding barriers and facilitators from the perspectives of people with dementia is essential to inform the future development of cognitive condition-related registries. The results from our focus groups identified engagement strategies and solutions to overcome perceived barriers for individuals experiencing progressive cognitive decline to participate in longitudinal registry projects.

The 2018 update of the Canadian Stroke Best Practice Recommendations for Acute Stroke Management, 6th edition, is a comprehensive summary of current evidence-based recommendations, appropriate for use by healthcare providers and system planners caring for persons with very recent symptoms of acute stroke or transient ischemic attack. The recommendations are intended for use by a interdisciplinary team of clinicians across a wide range of settings and highlight key elements involved in prehospital and Emergency Department care, acute treatments for ischemic stroke, and acute inpatient care. The most notable changes included in this 6th edition are the renaming of the module and its integration of the formerly separate modules on prehospital and emergency care and acute inpatient stroke care. The new module, Acute Stroke Management: Prehospital, Emergency Department, and Acute Inpatient Stroke Care is now a single, comprehensive module addressing the most important aspects of acute stroke care delivery. Other notable changes include the removal of two sections related to the emergency management of intracerebral hemorrhage and subarachnoid hemorrhage. These topics are covered in a new, dedicated module, to be released later this year. The most significant recommendation updates are for neuroimaging; the extension of the time window for endovascular thrombectomy treatment out to 24 h; considerations for treating a highly selected group of people with stroke of unknown time of onset; and recommendations for dual antiplatelet therapy for a limited duration after acute minor ischemic stroke and transient ischemic attack. This module also emphasizes the need for increased public and healthcare provider’s recognition of the signs of stroke and immediate actions to take; the important expanding role of paramedics and all emergency medical services personnel; arriving at a stroke-enabled Emergency Department without delay; and launching local healthcare institution code stroke protocols. Revisions have also been made to the recommendations for the triage and assessment of risk of recurrent stroke after transient ischemic attack/minor stroke and suggested urgency levels for investigations and initiation of management strategies. The goal of this updated guideline is to optimize stroke care across Canada, by reducing practice variations and reducing the gap between current knowledge and clinical practice.

Background The effectiveness of thrombolysis is highly time dependent. For this reason, short target times have been set to reduce time to treatment from hospital arrival, which is called door-to-needle time. Summary of review There has been considerable work done at single centers and across multiple hospitals to improve door-to-needle time. There have been reductions of 8 to 47 min when applying one or more improvement strategies at single centers, and there have been many multi-hospital initiatives. The delays to treatment have been attributed to both patient and hospital factors, and strategies to address these delays have been proven to reduce door-to-needle time. The most effective strategies include pre-notification of arrival by Emergency Medical Services (EMS), single-call activation of stroke team, rapid registration process, moving the patient to computed tomography on EMS stretcher, and administration of alteplase in the scanner. There are many exciting areas of future direction including reduction of door-to-needle time in developing countries, improving pre-hospital response times, and improving the efficiency of endovascular treatment. Conclusions There is now a broad understanding of the causes of delays to fast treatment and the strategies that can be employed to improve door-to-needle time such that most centers could achieve median door-to-needle time of 30 min.

Objective The best screening questionnaires for detecting post-stroke depression have not been identified. We aimed to validate four commonly used depression screening tools in stroke and transient ischemic attack patients. Methods Consecutive stroke and transient ischemic attack patients visiting an outpatient stroke clinic in Calgary, Alberta (Canada) completed a demographic questionnaire and four depression screening tools: Patient Health Questionnaire (PHQ)-9, PHQ-2, Hospital Anxiety and Depression Scale (HADS-D), and Geriatric Depression Scale (GDS-15). Participants then completed the Structured Clinical Interview for DSM-IV (SCID), the gold-standard for diagnosing major depression. The questionnaires were validated against the SCID and sensitivity and specificity were calculated at various cut-points. Optimal cut-points for each questionnaire were determined using receiver-operating curve analyses. Results Among 122 participants, 59.5% were diagnosed with stroke and 40.5% with transient ischemic attack. The point prevalence of SCID-diagnosed current major depression was 9.8%. At the optimal cut-points, the sensitivity and specificity for each screening tool were as follows: PHQ-9 (sensitivity: 81.8%, specificity: 97.1%), PHQ-2 (sensitivity: 75.0%, specificity: 96.3%), HADS-D (sensitivity: 63.6%, specificity: 98.1%), and GDS-15 (sensitivity: 45.5%, specificity: 84.8%). Areas under the receiver operating characteristic curves were as follows: PHQ-9 86.6%, PHQ-2 86.7%, HADS-D 85.9%, and GDS-15 66.3%. Conclusions The PHQ-2 and PHQ-9 are both suitable depression screening tools, taking less than 5 minutes to complete. The HADS-D does not appear to have any advantage over the PHQ-based scales, even though it was designed specifically for medically ill populations. The GDS-15 cannot be recommended for general use in a stroke clinic based on this study as it had worse discrimination due to low sensitivity.

Cerebral amyloid angiopathy (CAA) is a small-vessel disease preferentially affecting posterior brain regions. Recent evidence has demonstrated the efficacy of functional MRI in detecting CAA-related neurovascular injury, however, it is unknown whether such perturbations are associated with changes in the hemodynamic response function (HRF). Here we estimated HRFs from two different brain regions from block design activation data, in light of recent findings demonstrating how block designs can accurately reflect HRF parameter estimates while maximizing signal detection. Patients with a diagnosis of probable CAA and healthy controls performed motor and visual stimulation tasks. Time-to-peak (TTP), full-width at half-maximum (FWHM), and area under the curve (AUC) of the estimated HRFs were compared between groups and to MRI features associated with CAA including cerebral microbleed (CMB) count. Motor HRFs in CAA patients showed significantly wider FWHM ( P = 0.006) and delayed TTP ( P = 0.03) compared to controls. In the patient group, visual HRF FWHM was positively associated with CMB count ( P = 0.03). These findings indicate that hemodynamic abnormalities in patients with CAA may be reflected in HRFs estimated from block designs across different brain regions. Moreover, visual FWHM may be linked to structural MR indications associated with CAA.

Introduction Endovascular treatment of acute ischemic stroke is more effective when performed quickly. In this report, we describe quality interventions to ensure fast endovascular treatment times in the ESCAPE (Endovascular Treatment for Small Core and Anterior circulation Proximal Occlusion with Emphasis on Minimizing CT to Recanalization Times) trial. Methods An “audit and feedback” intervention using webinar and letter was used to improve treatment time over the course of the trial. The time metrics were computed tomography-to-groin-puncture (target Results There were 165 patients enrolled into the endovascular arm from 22 sites. The computed tomography-to-groin-puncture time dropped from 57 to 47 min (p = 0.14) while computed tomography-to-reperfusion time dropped from 89 to 81 min (p = 0.48). Over the course of the trial, the absolute treatment benefit increased by 7.8% (p Conclusions An “audit and feedback” intervention throughout the conduct of the ESCAPE trial was a feasible way to ensure fast treatment times. Quality improvement processes should continue as standard practice beyond the trial to encourage good patient selection and the best clinical outcomes.

There is no consensus on how the reliability and predictive ability of noncontrast computed tomography (NCCT) and computed tomography angiography source image (CTASI) change over time from acute ischemic stroke onset. We hypothesized that the reliability for detecting early ischemic changes (EIC) would be lower in early time periods and that changes identified on CTASI would be more reliable across examiners than changes identified on NCCT. To address this, we compared the relationships between CTASI, NCCT, and final infarct in patients with initial computed tomography (CT) imaging at different time points after stroke onset. Patients with acute ischemic stroke with proximal anterior circulation occlusions (internal carotid artery, middle carotid artery M1, proximal M2) from Calgary CT Angiography (CTA) database were studied. The cohort was categorized in four groups based on time from stroke onset to baseline NCCT/CTA: 0–90 mins ( n = 69), 91–180 mins ( n = 88), 181–360 mins ( n = 46), and >360 mins ( n = 58). Median scores of NCCT-Alberta Stroke Program Early CT Score (ASPECTS), CTASI ASPECTS, and follow-up ASPECTS among different time categories were compared. To determine reliability, a subsample of NCCT brain and CTASI were interpreted at separate sessions weeks apart by two neuroradiologists and two stroke neurologists in random order. Median and mean ASPECTS ratings on NCCT and CTASI were higher than final ASPECTS in each time category ( P < 0·001 for all comparisons). CTASI ASPECTS was lower than NCCT ASPECTS in each time category, and differences were significant at 0–90 mins and 91–180 mins ( P < 0·001). The least agreement among readers was in detection of EIC on NCCT brain in the ultra-early phase (

Background Patients with moderate to severe acute ischemic stroke without intracranial vessel occlusion are an intriguing subset of stroke patients. They pose diagnostic and therapeutic challenges to the physician. We sought to study these patients with an emphasis on their radiological and clinical outcomes. Methods This is a retrospective cohort study of ischemic stroke patients (NIHSS ≥ 6), with no intracranial vessel occlusion on computed tomography angiography within six-hours of symptom onset. Follow-up imaging – either computed tomography brain or magnetic resonance imaging – was performed within one- to seven-days. The primary outcome was modified Rankin Scale score ≤ 2 at three-months. Results In a database of 1308 patients, we identified 99 (7·6%) patients with NIHSS≥6 and no intracranial vessel occlusion on computed tomography angiography. The mean age was 67·8 ± 15·4 years and 60 (60·6%) were men. The median baseline NIHSS was nine (6–28). The initial computed tomography head was normal in 79 (79·8%) patients. Dramatic early clinical improvement at 24 h (NIHSS score ≤2 at 24 h or change between baseline and 24 h NIHSS score 15 points) was seen in 38 (38·4%) patients. Follow-up scans showed infarcts in 66 (66·7%) patients. Fifty (50·5%) patients received tissue plasminogen activator; one (2%) tissue plasminogen activator-treated patient developed symptomatic intracranial hemorrhage. At three-months; 59 (59·6%) patients were independent (modified Rankin Scale ≤2), 34 (34·3%) patients were dependent (modified Rankin Scale 3–5), and six (6·1%) were dead. The factors associated with the unlikelihood of good outcome were higher initial NIHSS (odds ratio 0·86 per additional point, 95% confidence interval 0·77–0·95, P = 0·003), and older age (odds ratio 0·95 per additional year, 95% confidence interval 0·92–0·98, P = 0·004). Conclusion Stroke without intracranial occlusions are not a benign entity. Factors that are independently associated with decreased likelihood of a good outcome are higher baseline NIHSS, and older age. Treatment with tissue plasminogen activator is not a predictor of outcome.

Background Stroke unit care improves outcomes following ischemic stroke. However, it is not known whether all ischemic stroke subtypes benefit equally from stroke unit admission. Objective To determine whether the benefit of stroke unit admission is similar among all ischemic stroke subtypes. Design, setting and patients Prospective cohort study including patients admitted with an acute ischemic stroke between July 2003 and September 2007 to stroke centers participating institutions in the Registry of the Canadian Stroke Network. Ischemic stroke subtype information was determined according to the modified Trial of Org 10 172 in Acute Stroke Treatment criteria and categorized as small vessel disease (lacunar), large artery atherosclerotic disease, cardioembolic, or other (including both other determined and undetermined causes). Main outcome measures The primary outcome measure was all-cause mortality at 30 days after stroke. Secondary outcomes were seven-day mortality and death or institutionalization at discharge. Results Among 6223 eligible patients with ischemic stroke admitted to regional stroke centers in Ontario, the mean age was 72 years and 52·4% were male. Overall 30-day mortality was 12·2%. The 30-day risk-adjusted mortality was lower for stroke unit care across all stroke subtypes (for lacunar stroke 3·0% vs. 5·3%; for large artery disease 7·5% vs. 14·5%; for cardioembolic 15·3% vs. 23·3%; and for other causes 8·9% vs. 15·9%). In multivariable analysis, after controlling for age, gender, medical comorbidities, and stroke severity, there was a significant reduction in stroke mortality associated with stroke unit admission in all stroke subtypes (odds ratio (95% confidence interval) for lacunar stroke 0·48 (0·27–0·88), for large artery atherosclerotic disease 0·39 (0·27–0·56), for cardioembolic 0·46 (0·36–0·59), and for other causes 0·45 (0·29–0·70)). The results remained similar after a sensitivity analysis excluding patients receiving palliative care, and a secondary analysis including 3215 patients with missing Trial of Org 10 172 in Acute Stroke Treatment classification. Conclusion This study provides ‘real-world’ evidence that all ischemic stroke subtypes do benefit from a stroke unit admission regardless of the etiology. There is no justification for withholding access to stroke unit care based on stroke subtype.