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Introduction: Social support may influence illness incidence or recovery through effects on health-related behaviors, and one aspect is emotional support, which includes the offering of empathy, friendship, care, and trust along with information. While we have previously reported on the positive relationship of family and friend networks in risk reduction, our objective was to examine whether participation in formalized group activities was related to medication adherence post-stroke. Methods: Using Discharge Educational Strategies for Reduction of Vascular Events (DESERVE) data, information regarding religious and nonreligious social activities was collected at baseline. The outcome variable was measured by the self-reported 8-item Morisky Medication Adherence Scale (MMAS-8; score 0-8). Medium/high adherence (MMAS-8≥6) at 6- and 12-months post-discharge was modeled against social activities separately using logistic regression adjusting for age, gender, race/ethnicity, education, family and friend networks, NIH stroke scale at admission, and the intervention. Results: Of the 541 participants who completed the baseline questionnaire, 286 and 344 had valid MMAS-8 scores for post 6-months and 12-months follow-up data collection. Medication adherence was poor among the participants. Only 44% for 6-months and 46% for 12-months had medium or high medication adherence. Participants going to nonreligious social events (n = 67, 21%) had higher odds of having medium/high medication adherence (OR = 3.08, 95% CI: 1.15-8.25) at 12-months. Discussion: Nonreligious social activities, including meetings of social clubs or other non-religious groups not relevant to work, were shown to be positively related to 12-months post-discharge medication adherence among stroke patients. Social activities may play an important role in emotional support and may be an opportunity for targeted secondary stroke prevention.

Introduction: Memory problems, a common cognitive issue, can have a negative influence on one’s ability to function and contributes to increased risk of secondary stroke. Objective: To examine the association between self-reported memory problems at 6 months and blood pressure control at 12 months post-stroke. Methods: This study utilized follow-up data from the Discharge Educational Strategies for Reduction of Vascular Events (DESERVE) stroke risk factor reduction trial (n=226). Sample size was restricted to those who answered memory questions and had a 12-month blood pressure (BP) reading. Exclusion criteria for DESERVE included any significant memory disorder prior to the baseline stroke. Seven memory domain questions (Table 1) from the Stroke Impact Scale were used separately to assess the association with systolic BP, with control defined as ≤120mmHg, at 12 months in logistic regression models adjusted for race, gender, education, age, and intervention status. Models were additionally adjusted for 6-month BP control as a mediator. Results: Participants were almost equally white (28%), Black (33%), or Hispanic (34%) and 52% were female with a mean age of 65 (SD=13). About 25% had BP control at 6 or 12 months. Memory measures were not significantly associated with BP control prior to adjusting for BP control at 6 months. After adjusting for 6-month BP control, participants with less difficulty remembering things that people just told them (OR=1.69, 95% CI: 1.09, 2.63) or remembering to do things (OR=1.76, 95% CI:1.09, 2.86) had better odds of having their BP controlled at 12 months. Memory items 2 and 4-7 did not show an association with better BP control. Discussion: Stroke survivors who were better at remembering what people told them and remembering to do things were more likely to achieve blood pressure control 1-year post-stroke. Evaluating early memory post-stroke may be an important target for secondary prevention strategies and should be further researched.

Background: Social networks provide emotional and social support that may help prevent the onset of secondary stroke. Little is known about egocentric networks among stroke survivors and the type of support they provide. Objective: To develop an understanding of the supportive role alters or personal contacts provide to stroke survivors and gain insight of participants' egocentric network. Methods: Data obtained from the Discharge Educational Strategies for Reduction of Vascular Events (DESERVE) trial, a skills-based, culturally tailored discharge educational intervention. Participants (n=552) identified up to 5 alters. Descriptive analyses were conducted to assess the relationship between participants and alters. Results: Approximately, 34% of participants identified as Non-Hispanic (NH) Black followed by Hispanic (33%), NH White (28%), NH Asian Pacific Islanders (API) (3%). Majority of participants (n=462, 83%) reported having at least one alter. Most participants with ≥1 alter (92%) indicated talking to alter every day or several times a week. Yet all with an alter stated that they can talk to alter about an important health problem or medical decision. Among participants (n=543, p=.002), NH Blacks (n=38, 45%) and Hispanic (n=33, 39%) were more likely to report no alters compared to NH White (n=14, 16%; Figure). Conclusions: Majority of participants reported having at least one person within their social network that they can talk to about their health problems. We are unable to determine if the first person that participants indicated may be the most influential person in health-related matters. The implications of these results may be relevant for future stroke interventions. Additional studies are needed to understand the type of influence alters have on stroke survivors in health-related behaviors and decisions that may help improve post-stroke outcomes. Further studies are also needed to assess health outcomes among isolated stroke patients by race.

Background: In the continuum of care for stroke survivors, racial-ethnic disparities are most prominent during post-stroke rehabilitation. This includes reintegration of stroke survivors to normal living, an important component in stroke rehabilitation and predicts stroke survivors’ participation in typical daily activities and post-stroke depression. We assessed the association between racial-ethnic factors and ability of survivors to reintegrate to normal living at one-year post stroke. Methods: Using data from the DESERVE (Discharge Educational Strategies for Reduction of Vascular Events) trial, we assessed reintegration to normal living (RNL) using the RNL index of 335 participants with acute stroke. Race and ethnicity were asked at baseline and the survivors’ RNL index was assessed at one-year follow-up. The RNL index was calculated from 11 questions rating survivor’s reintegration from 0-10 (no to complete integration). We used linear regression to assess variations in race-ethnicity on RNL index adjusting for intervention, age, sex, education, living arrangement, stroke history, and severity of recent stroke. Results: At baseline, 27.8% identified as Non-Hispanic (NH) white, 31.6% identified as NH black, 34.9% identified as Hispanic and 5.7% identified as NH other. Crude mean RNL index was greater in the intervention arm than the usual care arm for Hispanics and NH blacks (Figure). In adjusted models, NH whites (5.88, CI: -2.9,14.8) and NH Blacks (6.63, CI: -1.1,14.3) had higher RNL index compared to Hispanics. Conclusion: Racial-ethnic differences may play a clinically important role in reintegrating stroke survivors to normal living. Future interventions must be aimed at understanding fundamental causes of disparities that may lead to inequities in stroke survivors’ rehabilitation to better implement preventative strategies well before stroke incidence.

Introduction: Beliefs regarding ones’ control over their health can lie internally, influenced by their own actions, or externally, controlled by others or due to chance. Objective: To examine the association between health-related locus of control (HRLC) type and post-stroke disability, quality of life, and depression. Methods: This study utilized data from the Discharge Educational Strategies for Reduction of Vascular Events (DESERVE) trial (n=552). Participants were categorized into three groups based on their highest Multidimensional Health Locus of Control (MHLC) score. The Stroke Impact Scale (SIS) was used to assess post-stroke disability and quality of life. Linear regression was used to identify differences in each SIS domain score between the three groups while adjusting for the intervention. Depression was defined as a Center for Epidemiological Studies Depression (CESD) score ≥16. Logistic regression was used to examine differences in depression between the three groups while adjusting for the intervention. Results: Of the 529 participants who completed the MHLC questionnaire at baseline, 179 (33.3%) were categorized into the internal group , 163 (30.8%) into the powerful others group, and 190 (35.9%) into the chance group. Of the 297 participants who completed the CESD questionnaires at 12 months, 163 (54.8%) scored ≥ 16. Participant’s mean scores for each SIS domain are reported in Table 1. For the SIS communication domain, the chance group’s mean score was 3.03 points lower than the powerful others group’s score (SE=1.39, p=.029). There were no statistically significant differences in scores for the other seven SIS domains or for depression between groups (Table 1). Discussion: External HRLC based on chance may be a predictor of communication difficulties in patients post-stroke. However, mean communication scores are skewed. Control beliefs are important in post-stroke recovery. More research is needed to validate these findings.

Introduction: Racial discrimination has existed for centuries in the US and contributes to disparities in stroke and stroke outcomes. Measures of structural racism have been used to quantify these disparities. Our objective was to determine if the efficacy of a skills-based intervention on blood pressure reduction in a cohort of mild/moderate strokes varied by historic redlining, the US Federal government’s sanctioned discrimination in mortgage risk assessment. Methods: The Discharge Educational Strategies for Reduction of Vascular Events (DESERVE) intervention randomized 552 participants to a skills-based intervention or usual care. Participants addresses were geocoded and linked to federally sponsored Home Owners’ Loan Corporation (HOLC) color-coded maps from the 1930s. Participants residing in graded locations (n=279) were given weighted historic redlining scores (HRS) calculated using the proportion of 1930s HOLC residential security grades contained within 2010 census tract boundaries and a discrimination score based current lending practices. The change in systolic blood pressure was modeled linearly with generalized estimating equations used to account for clustering by site. Results: Participants were 34% Hispanic, 31% non-Hispanic Black, 28% non-Hispanic white, and 7% other race. The intervention was most efficacious in areas of persistent (Δ=6.05 mmHg reduction; p=0.003) and declining discrimination (Δ=11.08 mmHg reduction; p=0.007) versus usual care. In areas that were gentrifying, the intervention was least efficacious (Δ=7.33mmHg increase; p=0.022) and minimal in areas of no discrimination (Δ=0.054 mmHg reduction; p=0.903). Conclusions: Historic redlining practices are a form of structural racism that established geographic systems of disadvantage. The efficacy of interventions are impacted by underlying systems of disadvantage such that contextual factors beyond race must be considered when designing trials.

Introduction: Racial disparities exist in stroke and stroke outcomes. However, the fundamental cause for these disparities are not biological differences, but structural racism. Using the Home Owners’ Loan Corporation (HOLC) ‘redlining’ scores, as indicator of structural lending practices from middle of the last century, we hypothesize that census tracts with high historic redlining are associated with higher stroke prevalence. Methods: Weighted historic redlining scores (HRS) were calculated using the proportion of 1930s HOLC residential security grades contained within 2010 census tract boundaries of Columbus, Ohio. Stroke prevalence (adults >=18) was obtained at the census tract-level from the CDC’s 500 Cities Project. Sociodemographic factors, as measured by census tract level information (American Community Survey 2014-2018), were considered mediators in the causal association between historic redlining (measured in 1936) and stroke prevalence (measured in 2017) and were not controlled for in regression analysis. The functional form of the association was non-linear, so stroke prevalence within quartiles of the HRS were compared using linear regression instead of a continuous score. Results: Higher HRS, representing greater redlining, were associated with greater prevalence of stroke when comparing the highest to the lowest quartile of HRS (Figure). Census tracts in the highest quartile of HRS had 1.48% higher stroke prevalence compared to those in the lowest quartile (95% CI: 0.23-2.74). No other interquartile differences were observed. Conclusions: Historic redlining practices are a form of structural racism that established geographic systems of disadvantage and consequently, poor health outcomes. Our findings demonstrate disparate stroke prevalence by degree of historic redlining in census tracts across Columbus, Ohio. While ecologic, this study demonstrates the need to acknowledge that racism, not race, drive stroke disparities.

Introduction: Presence of functional leptomeningeal collaterals has been found to be one of the key determinants of good outcomes. We evaluated the effects of certain environmental and physical factors in cerebral collateral circulation. Methods: After IRB approval, data was collected from prospective institutional Neurocritical Care and Stroke Registry. Stroke patients presenting with acute anterior circulation large vessel occlusion between May 2013 and August 2018 were included. Collaterals were graded based on CT-Angiogram and CT-Perfusion images obtained on presentation, by a blinded Neuroradiologist as good (grade 3-4) and poor (grades 0-2). Ohio air pollution data (2013-2018) were obtained from the US EPA and summarized as a single mean concentration by monitor. Strokes were geocoded and linked with the closest monitor. Odds of good (vs. poor) collateral grade were compared using BMI (linear), smoking status, antiplatelet medication use, and mean PM 2.5 concentration (cubic). Sensitivity analyses assessed additional adjustment by sex and change in NIHSS (admission to discharge). Results: A total of 73 strokes were analyzed with 48% male, mean BMI of 30.4 (SD=7.2), and 22% with good collateral grade. For each kg/m 2 greater BMI, the odds of having good collaterals (vs. poor) were 11% higher (OR: 1.11; 95%CI:1.01-1.22; p =0.029). Higher PM 2.5 concentrations were suggestive of lower odds of good collaterals ( p =0.124). Antiplatelet medication use (OR: 2.10; 95%CI:0.59-7.45) and smoking status (OR: 1.35; 95%CI:0.73-13.9) were not associated with the odds of having good collateral grade. After controlling for change in NIHSS and sex, higher BMI remained associated with good collateral grade (fig.1). Conclusions: Higher BMI was independently associated with higher odds of good collateral grade; this association needs to be explored in larger population taking other factors like age and medical comorbidities into account.

Introduction: There is substantial variability in current estimation and communication of stroke prognosis. Existing predictive models have focused on dichotomous outcomes (e.g. functional independence or not), though other outcomes may also be of importance to patients and families. Our objective was to create an ordinal prognostic model to predict the full range of functional outcome (modified Rankin Scale (mRS)) at 90 days after intracerebral hemorrhage. Methods: We used anonymized data from the Virtual International Stroke Trials Archive (VISTA), comprising individuals from both clinical trials and registries. The 90-day mRS was modeled using a proportional odds model. Potential predictors were selected a priori from available data including age, sex, comorbidities, and initial stroke severity. The best model was chosen based on fit statistics using a stepwise selection approach, internally validated using bootstrapping procedures, and externally validated using a population-based sample of 126 ICH cases from southeast Texas. Results: A total of 1097 ICH cases were used in model building, with 95% from clinical trials. Cases were 63% male, with an average age of 66.7 years (SD=12.0), a median stroke severity of 13 (NIHSS) and 23% had a history of stroke. The final predictive model included 6 variables (age, sex, NIHSS, AFIB, diabetes, and prior stroke) and discriminated well between mRS scores (c-statistic=0.743), with minor optimism after bootstrap resampling (corrected c-statistic=0.740). The model yielded good discrimination in the external data set (c-statistic=0.774). Examples of model output are shown in the Figure. Conclusions: This calibrated, internally and externally validated ordinal prognostic model to predict the full range of 90-day functional outcome will be tested as a part of an ongoing study to develop an educational decision support tool for stroke surrogate decision makers (NCT0342764).

Background and Purpose— Little is known about the relation between environment and stroke severity. We investigated associations between environmental exposures, including neighborhood socioeconomic disadvantage and short-term exposure to airborne particulate matter Methods— First-ever ischemic stroke cases were identified from the Brain Attack Surveillance in Corpus Christi project (2000–2012). Associations between pollutants, disadvantage, and National Institutes of Health Stroke Scale were modeled using linear and logistic regression with adjustment for demographics and risk factors. Pollutants and disadvantage were modeled individually, jointly, and with interactions. Results— Higher disadvantage scores and previous-day ozone concentrations were associated with higher odds of severe stroke. Higher levels of particulate matter P interaction =0.097). Conclusions— Air pollution exposures and neighborhood socioeconomic status may be important in understanding stroke severity. Future work should consider the multiple levels of influence on this important stroke outcome.

Background and Purpose— Acute stroke education has focused on stroke symptom recognition. Lack of education about stroke preparedness and appropriate actions may prevent people from seeking immediate care. Few interventions have rigorously evaluated preparedness strategies in multiethnic community settings. Methods— The Acute Stroke Program of Interventions Addressing Racial and Ethnic Disparities (ASPIRE) project is a multilevel program using a community-engaged approach to stroke preparedness targeted to underserved black communities in the District of Columbia. This intervention aimed to decrease acute stroke presentation times and increase intravenous tissue-type plasminogen activator utilization for acute ischemic stroke. Results— Phase 1 included (1) enhancement of focus of emergency medical services on acute stroke; (2) hospital collaborations to implement and enrich acute stroke protocols and transition District of Columbia hospitals toward primary stroke center certification; and (3) preintervention acute stroke patient data collection in all 7 acute care District of Columbia hospitals. A community advisory committee, focus groups, and surveys identified perceptions of barriers to emergency stroke care. Phase 2 included a pilot intervention and subsequent citywide intervention rollout. A total of 531 community interventions were conducted, reaching >10 256 participants; 3289 intervention evaluations were performed, and 19 000 preparedness bracelets and 14 000 stroke warning magnets were distributed. Phase 3 included an evaluation of emergency medical services and hospital processes for acute stroke care and a year-long postintervention acute stroke data collection period to assess changes in intravenous tissue-type plasminogen utilization. Conclusions— We report the methods, feasibility, and preintervention data collection efforts of the ASPIRE intervention. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00724555.

Background and Purpose: Diabetes mellitus (DM) is a well-established risk factor for ischemic stroke (IS), but the literature is inconsistent on the effect of DM on outcomes after IS. We sought to determine if DM increases the risk of mortality and recurrence after IS, and if these associations are greater in Mexican Americans (MA) than non-Hispanic whites (NHW). Methods: IS cases, all-cause mortality, and recurrent strokes were identified from the Brain Attack Surveillance in Corpus Christi (BASIC) project (2006-2012). Sociodemographics and clinical data were obtained from medical records and interviews. Cumulative mortality and stroke recurrence risk were estimated at 30 days and 1 year using Kaplan-Meier analysis and Cox proportional hazards models. Effect modification by ethnicity was examined. Results: There were 1,301 IS cases, 46% with a history of DM, median age 70 (IQR: 58-81), and 61% MA. Patients with DM were younger and more likely to be MA compared to patients without DM. Risk of 30-day and 1-year mortality was 8.4% and 20.5% for those with DM and 9.5% and 20.8% for those without DM, respectively. Risk of 30-day and 1-year stroke recurrence was 1.2% and 7.5% for those with DM and 1.5% and 5.8% for those without DM, respectively. Unadjusted, DM was not a significant predictor of mortality or recurrence (see table). After adjustment, DM predicted mortality (30-day HR=1.58, 95% CI: 0.98-2.53; 1-year HR=1.48, 95% CI: 1.10-2.00) but not stroke recurrence (1-year HR=1.28, 95% CI: 0.78-2.08). Effect modification by ethnicity was not significant (p>0.2 for all models). Conclusions: Given that patients with DM were significantly younger than patients without DM, the crude association between DM and mortality revealed no difference. However, after accounting for age and other factors, patients with DM were 50% more likely to die at 1 year after IS compared to patients without DM.

Background: Recurrent strokes are associated with poor outcomes and mortality. Short-term ambient air pollution may be an important environmental risk factor for stroke recurrence. Although associations between air pollution and stroke risk have been observed, the evidence for short-term effects of air pollution on risk of stroke recurrence is in its infancy. We investigated the association between short-term changes in ambient pollution (particulate matter 2.5 ) and ozone (O 3 )) and the risk of recurrent ischemic stroke among individuals living in a bi-ethnic community. Methods: We identified recurrent ischemic stroke cases from the population-based Brain Attack Surveillance in Corpus Christi (BASIC) Project, an ongoing population-based stroke surveillance study in Nueces County, Texas, between 2000 and 2012. Associations between lags of 0 to 3 days PM 2.5 and O 3 levels and odds of ischemic stroke were assessed using a time-stratified case-crossover design. Conditional logistic regression models were used to calculate odds ratios (ORs) for a 10 unit change in exposure. Results: There were 317 recurrent ischemic strokes with mean age of 72 years (SD=12). Median levels of PM 2.5 and O 3 over the study period were 7.7μg/m 3 (IQR: 5.6-10.7μg/m 3 ) and 35.2ppb (IQR: 25.0-46.1ppb), respectively. No associations were observed across the different lagged exposures (0 to 3 days) after adjusting for ambient temperature and relative humidity (Figure). Co-adjustment of both pollutants results did not change the results. Conclusion: No association between PM 2.5 and O 3 and risk of recurrences was observed. Research on the influence of air pollutants on risk of recurrence is still in its infancy, and more research is needed to understand the relation.

Introduction: Previous studies exploring stroke caregiving have estimated that the average stroke survivor receives as many as 16 hours per week hours of informal caregiving at a societal cost of as much as $26.8 billion per year. However, these studies have focused on basic and instrumental activities of daily living, and have not included healthcare and transportation activities. We sought to determine whether, and at what cost, caregiving differs between stroke survivors and matched controls using an expanded definition of caregiving. Methods: A total of 892 stroke survivors were drawn from the 2011 wave of the National Health and Aging Trends Study (NHATS), a nationally representative survey of Medicare beneficiaries. One-to-one propensity matching was performed on demographics and comorbidities to create a sample of matched non-stroke controls. Caregivers were identified by detecting all helpers for NHATS respondents who had help with self-care or mobility activities or with household activities due to health or functioning. Stroke survivors and controls were compared using survey-weighted chi-square tests and Wald tests. The annual cost of caregiving was estimated using reported paid caregiving data and estimates of informal caregiving costs. Results: On average, stroke survivors received about 10 hours of additional caregiving per week compared to controls (22 hours vs. 12 hours, p Conclusion: Our expanded definition of caregiving suggests that prior studies may underestimate both the time and costs invested in caregiving to older stroke survivors.

Background: National data shows that African Americans (AA) are less likely to fall than whites. However, the reasons for this difference and whether it is true amongst stroke survivors are unknown. We hypothesized that AA stroke survivors fall less than white stroke survivors, and sought to understand which risk factors drive racial differences. Methods: Data from the 2011 wave of National Health and Aging Trends Study (NHATs), a nationally representative population of community-dwelling adults over 65, were used. We compared the prevalence of self-reported falling in the past year between AA and white stroke survivors using Poisson regression models. Models were adjusted for groups of variables that may predict race-based differences in falls: sociodemographic, comorbidity, capacity, fall risk factor, fall access, and environment. Race-specific predictive margins and prevalence ratios (PR) were calculated. Results: The sample included 806 stroke survivors; 581 white and 228 AA. AAs had lower income, physical and cognitive capacity, were less likely to be married, to go outside, to have osteoporosis, and lived in worse neighborhood environments compared to white stroke survivors. Unadjusted, prevalence of falling in the past year was similar comparing AA to whites (PR: 0.89, p=0.2). Adjustment for sociodemographic variables produced a marginal racial difference, which became statistically significant after adding physical and cognitive capacity measures (Table). After full adjustment, AA were 30% less likely to have reported a fall compared to whites (p=0.004). Conclusions: African American stroke survivors are significantly less likely to report falling in the previous year compared to whites. Differences in sociodemographics and capacity may be most influential, yet other factors did not account for differences in fall prevalence. Further study of falls among AA stroke survivors may provide insight to decrease falls among other racial/ethnic groups.

Introduction: Lost earnings are the largest driver of the projected $2.2 trillion in stroke costs over the next 4 decades. Mexican Americans (MA) are more likely to have a working age stroke and suffer greater post-stroke disability than non-Hispanic whites (NHW). Thus, we explored ethnic differences in post-stroke return to work and whether sociodemographics and stroke severity contribute to ethnic differences. Methods: Ischemic stroke patients were identified from the population-based Brain Attack Surveillance in Corpus Christi (BASIC) study from August 2011-December 2013. Employment status was obtained at baseline and 90-day interviews conducted with patients or proxies. Sequential logistic regression models were built to assess ethnic difference in return to work after accounting for: 1) age ( Results: Of the 729 MA and NHW stroke survivors who completed the baseline interview, 197 (27%) were working at the time of their stroke of which 125 completed the 90-day outcome interview. There were no ethnic differences in sex or the proportion over the age of 65. MAs had less education (5% vs. 24% college graduate, p Conclusion: MAs are less likely to return to work after stroke than NHWs. This finding is important given that MAs are younger and poorer at the time of their stroke suggesting a crucial public health problem. Future work should consider including return to work as part of patient centered outcomes and efforts to optimize stroke recovery.

Background and Purpose— Previous studies exploring stroke-related caregiving focused solely on informal caregiving and a relatively limited set of activities. We sought to determine whether, and at what cost, stroke survivors receive more care than matched controls using an expanded definition of caregiving and inclusion of paid caregivers. Methods— Data were drawn from the National Health and Aging Trends Study (NHATS), a nationally representative survey of Medicare beneficiaries. NHATS personnel conducted in-person interviews with respondents or proxies to determine the weekly hours of care received. We compared hours of assistance received between self-reported stroke survivors (n=892) and demography- and comorbidity-matched nonstroke controls (n=892). The annual cost of stroke caregiving was estimated using reported paid caregiving data and estimates of unpaid caregiving costs. Results— Of community-dwelling elderly stroke survivors, 51.4% received help from a caregiver. Stroke survivors received an average of 10 hours of additional care per week compared with demography- and comorbidity-matched controls (22.3 hours versus 11.8 hours; P Conclusions— Although stroke survivors are known to require considerable caregiving resources, our findings suggest that previous assessments may underestimate hours of care received and hence costs.

Background and Purpose— We sought to describe the association of spirituality, optimism, fatalism, and depressive symptoms with initial stroke severity, stroke recurrence, and poststroke mortality. Methods— Stroke cases from June 2004 to December 2008 were ascertained in Nueces County, TX. Patients without aphasia were queried on their recall of depressive symptoms, fatalism, optimism, and nonorganizational spirituality before stroke using validated scales. The association between scales and stroke outcomes was studied using multiple linear regression with log-transformed National Institutes of Health Stroke Scale and Cox proportional hazards regression for recurrence and mortality. Results— Six hundred sixty-nine patients participated; 48.7% were women. In fully adjusted models, an increase in fatalism from the first to third quartile was associated with all-cause mortality (hazard ratio, 1.41; 95% CI, 1.06–1.88) and marginally associated with risk of recurrence (hazard ratio, 1.35; 95% CI, 0.97–1.88), but not stroke severity. Similarly, an increase in depressive symptoms was associated with increased mortality (hazard ratio, 1.32; 95% CI, 1.02–1.72), marginally associated with stroke recurrence (HR, 1.22; 95% CI, 0.93–1.62), and with a 9.0% increase in stroke severity (95% CI, 0.01–18.0). Depressive symptoms altered the fatalism–mortality association such that the association of fatalism and mortality was more pronounced for patients reporting no depressive symptoms. Neither spirituality nor optimism conferred a significant effect on stroke severity, recurrence, or mortality. Conclusions— Among patients who have already had a stroke, self-described prestroke depressive symptoms and fatalism, but not optimism or spirituality, are associated with increased risk of stroke recurrence and mortality. Unconventional risk factors may explain some of the variability in stroke outcomes observed in populations and may be novel targets for intervention.

Background and Purpose— Few patients arrive early enough at hospitals to be eligible for emergent stroke treatment. There may be barriers specific to underserved, urban populations that need to be identified before effective educational interventions to reduce delay times can be developed. Methods— A survey of respondents' likely action in a hypothetical stroke situation was given to 253 community volunteers in the catchment areas of a large urban community hospital. Concurrently, 100 structured interviews were conducted in the same hospital with patients with acute stroke or a proxy. Results— In this predominantly urban, black population, if faced with a hypothetical stroke, 89% of community volunteers surveyed said they would call 911 first, and few felt any of the suggested potential barriers applied to them. However, only 12% of patients with stroke interviewed actually called 911 first (OR, 63.9; 95% CI, 29.5 to 138.2). Instead, 75% called a relative/friend. Eighty-nine percent of patients with stroke reported significant delay in seeking medical attention, and almost half said the reason for the delay was thinking the symptoms were not serious and/or they would self-resolve. For those arriving by ambulance, only 25% did so because they thought it would be faster, whereas 35% cited having no other transportation options. Conclusions— In this predominantly black urban population, although 89% of community volunteers report the intent of calling 911 during a stroke, only 12% of actual patients with stroke did so. Further research is needed to determine and conquer the barriers between behavioral intent and actual behavior to call 911 for witnessed stroke.

Background and Purpose— Mexican Americans (MAs) have an increased risk of stroke and experience worse poststroke disability than non-Hispanic whites, which may translate into worse poststroke quality of life (QOL). We assessed ethnic differences in poststroke QOL, as well as potential modification of associations by age, sex, and initial stroke severity. Methods— Ischemic stroke survivors were identified through the biethnic, population-based Brain Attack Surveillance in Corpus Christi (BASIC) Project. Data were collected from medical records, baseline interviews, and 90-day poststroke interviews. Poststroke QOL was measured at ≈90 days by the validated short-form stroke-specific QOL in 3 domains: overall, physical, and psychosocial (range, 0–5; higher scores represent better QOL). Tobit regression was used to model associations between ethnicity and poststroke QOL scores, adjusted for demographics, clinical characteristics, and prestroke cognition and function. Results— Among 290 eligible stroke survivors (66% MA, 34% non-Hispanic whites, median age=69 years), median scores for overall, physical, and psychosocial poststroke QOL were 3.3, 3.8, and 2.7, respectively. Poststroke QOL was lower for MAs than non-Hispanic whites both overall (mean difference, −0.30; 95% confidence interval, −0.59, −0.01) and in the physical domain (mean difference, −0.47; 95% confidence interval, −0.81, −0.14) after multivariable adjustment. No ethnic difference was found in the psychosocial domain. Age modified the associations between ethnicity and poststroke QOL such that differences were present in older but not in younger ages. Conclusions— Disparities exist in poststroke QOL for MAs and seem to be driven by differences in older stroke patients. Targeted interventions to improve outcomes among MA stroke survivors are urgently needed.

Background: Stroke risk and severity are patterned by neighborhood socioeconomic disadvantage (ND). Air pollution may also influence stroke severity through biologic mechanisms. We sought to identify potential synergistic effects of ND and air pollution on initial stroke severity in a large population-based stroke study. Methods: We identified incident ischemic stroke cases from the BASIC project from 2000-2012. NIH Stroke Scale (NIHSS) was determined from the medical record or abstracted. Particulate matter (PM2.5) and ozone (O3) data were obtained from a state website. An ND score was created for census tracts (proxy for neighborhood) of residence using 12 Census variables. The association between pollutants, ND, and NIHSS was modeled continuously (NIHSS score) and dichotomously (upper quartile (≥7) vs. lower quartiles ( Results: A total of 3,035 ischemic strokes occurred; mean age was 70 (SD=13), 51% female and 53% Mexican American. The difference from the 10th to 90th percentile of the ND score (more disadvantage) was associated with a 24% (95% CI: 0.98 - 1.57) higher odds of severe stroke (Table). Higher previous-day O3 levels were associated with both continuous NIHSS and severe stroke in single and dual exposure models; these associations were not modified by ND. Larger associations between PM2.5 and severe stroke were found for those in higher ND areas than those in lower ND areas (p=0.03). Same-day PM2.5 was not associated with continuous NIHSS nor modified by ND. Conclusion: Synergistic effects of air pollution and ND score on stroke severity existed; increases in PM2.5 were associated with greater odds of severe stroke as ND increased.

Background: Lack of education about stroke preparedness and needed action, particularly in underserved communities may prevent seeking timely care. Aim: To evaluate the Acute Stroke Program of Interventions Addressing Racial and Ethnic Disparities (ASPIRE) project. Methods: ASPIRE is a multi-level program [individual/community, hospital, EMS] using a community-engaged approach to stroke preparedness targeted to underserved black DC communities. The aim is to decrease acute stroke (AS) presentation times and increase intravenous tissue plasminogen activator (IV tPA) use. Phase 1 included 1) Enhancement of EMS focus on AS; 2) Implementation/enrichment of AS protocols to move DC hospitals to Primary Stroke certification; 3) Pre-intervention (PRE) AS patient data collection in all 7 acute care DC hospitals; 4) Focus group/survey identification of barriers to emergency stroke care to create a culturally tailored intervention. Phase 2 was a 1 year city-wide intervention. Phase 3 was 1 year post-intervention (POST) acute stroke data collection to assess changes in IV tPA use and AS presentation time. We compare PRE vs. POST AS parameters among ischemic stroke cases that arrived within 168 hours of stroke onset, excluding hospital transfers (n=84). We performed logistic regression models for AS arrival ≤ 3 hours. Results: Phase 1 identified 687 ischemic stroke cases, 85% black, 58% women; 56% ≥ 65 yrs. Phase 2 conducted 531 community interventions for 10,256+ participants; performed 3,289 intervention evaluations; distributed 19,000 preparedness bracelets and 14,000 stroke warning magnets. In Phase 3, we identified 684 ischemic stroke cases, 79% black, 58% women; 56% ≥ 65 yrs. We report significant increases in AS arrival time ≤ 3 hours (14% to 27%; p Conclusion: ASPIRE shows significant success increasing the proportion of AS arrivals to ED ≤ 3 hours and increasing IV tPA utilization. Culturally tailored community interventions can be effective in increasing stroke preparedness in underserved urban communities.

Background: Ethnic differences in stroke severity may vary by age or be explained by differences in risk factors (e.g. atrial fibrillation (Afib), diabetes). Our goal was to investigate ethnic differences in initial stroke severity. Methods: Ischemic stroke cases were identified from the population-based BASIC project. NIHSS was determined from the medical record or abstracted from the chart. Ethnicity was ascertained from the medical records and reported as Mexican American (MA) or non-Hispanic white (NHW). Quantile regression was used to model the distribution of NIHSS by age group (45-59, 60-74, 75+) to test whether ethnic differences exist over different quantiles of NIHSS (5% increments). Crude models were run to examine the interaction between age group and ethnicity; models were then adjusted for hypertension, Afib, coronary artery disease, and diabetes. Results were adjusted for multiple comparisons across 19 quantiles (5 to 95%). Results: There were 4,366 ischemic strokes, with median age 72 years (IQR: 61-81), 55% MA and median NIHSS of 4 (IQR: 2-8). In the crude model, in younger (45-59) and older (75+) age groups, MAs had one point higher NIHSS than NHWs at the median and for some lower quantiles (all p Conclusion: Ethnic differences in initial stroke severity varied by age. Age should be considered when looking at race/ethnic differences in severity.

Background: We previously reported racial differences in neurocognitive outcomes assessed 1 year after primary ICH in the DiffErenCes in the Imaging of Primary Hemorrhage based on Ethnicity or Race (DECIPHER) study.. We now analyze MR imaging findings associated with cognitive impairment in this cohort. Methods: Inclusion criteria were primary ICH, age >18, MRI at baseline, neurocognitive outcomes measured at 30 days and 1 year. Domains assessed included memory, executive function, attention, verbal fluency, depression and functional outcome. African American normative data were used to establish cut-points. The following variables were evaluated on MRI: evidence of prior stroke, hemorrhage volume and location, presence of microbleeds, and severity of white matter disease (WMD). Independent t- tests, chi-square, or Fisher’s exact tests were used as appropriate to compare differences between groups at 30 days and 1 year. Results: Of 192 subjects enrolled, mean age was 59 ± 13 years, 47% were female, and 76 % were black. Mean NIHSS was 10 (median 7). Neurocognitive outcomes were available for 144 subjects at 30 days and 126 at 1 year. Significant impairment was observed for all domains at each interval: memory (30 days 90%, 1 year 86%), verbal fluency (30 days 83%, 1 year 74%), attention (30 days 50%, 1 year 52%), and executive function (30 days 51%, 1 year 54%). Dementia was present in 22% at 30 days and 13% at 1 year. At 1 Year, hemorrhage location was not significantly associated with cognitive impairment, however, evidence of prior stroke was associated with impaired executive function (p6 associated with impaired memory (p 2 (p Conclusion: While the overall rates of neurocognitive and functional impairment decreased over time significant effects of primary ICH persist at 1 year and are associated with MR imaging findings of underlying vascular small vessel injury, including the presence of microbleeds and white matter disease.

Background: Racial disparities in ischemic stroke incidence have been found in previous studies with blacks having higher rates compared to whites. Recent data has suggested a decrease in stroke incidence but not necessarily a decrease in race differentials. We sought to document incidence of ischemic stroke and explore race-ethnic differentials in the urban, Washington, DC metro area. METHODS: ASPIRE is a multi-dimensional intervention with a three-pronged approach (community, hospital, EMS) to acute stroke preparedness targeted to increase IV tPA utilization in underserved black communities in DC. Using a comprehensive active and passive surveillance strategy including stroke admission alerts, stroke champions, admission/discharge data and chart review, the ASPIRE research team prospectively identified all hospitalized incident ischemic strokes between January 2008 and July 2012. Direct age-adjusted rates were estimated using age specific proportions from the 2010 census of the DC population for each sex, gender and race subgroup. RESULTS: Over 4.5 years, we captured 691 incident ischemic strokes: mean age 67 yrs +/- 15 yrs; 79% were blacks; and 55% females. Over 45% of the incident ischemic strokes occurred in black-females. Risk factors including hypertension (79%), diabetes (39%), and current smoking (28%) were significantly greater for blacks than whites. The age-adjusted average annual incidence rate per 100,000 was 226 overall: 171 for blacks, 45 for whites; 65 for black-males; 19 for white-males; 106 for black-females; and 26 for white-females CONCLUSION: We report significant racial disparities in the incidence of hospitalized ischemic in the DC metro area despite potential undercounting of non-hospitalized stroke cases, and potential competing mortalities in black men (ie. ICH, homicide, AIDS). This continued excess burden of ischemic stroke, particularly in black females, highlights the ongoing importance of projects such as ASPIRE to continue education and preparedness among those with increased risk.

BACKGROUND: There is sparse data about the nature of race-ethnic disparities in the acute stroke setting including differentials in stroke preparedness. The aim of this analysis was to explore race-ethnic differentials in time to arrival for acute stroke in a racial and ethnically diverse urban setting. METHODS: ASPIRE is a multi-dimensional intervention program (community, hospital, and EMS) for acute stroke preparedness targeted to increase IV tPA utilization in underserved black communities in the DC metro area. We prospectively identified stroke admissions and EMS utilization including acute stroke arrival time parameters for the 6 month pre and post intervention periods. Cox proportional hazards models were used to examine predictors of arrival time. Proportionality of the hazards was checked. RESULTS: In the 6 month pre-intervention period, data was collected on 943 stroke cases; 53% female; 74% black; mean age 67 yrs. Of the subjects from the pre-intervention period with arrival times less than 48 hrs, the median arrival time to the emergency department (ED) was 9 hours; 20% presented under 3 hours. In multivariable Cox PH models, subjects were 38% more likely to arrive earlier if they had arrived by EMS (HR: 1.38, 95%CI: 1.21-1.58). Black subjects were 25% less likely to arrive earlier (HR: 0.75, 95%CI: 0.60-0.93), but this effect was dampened over time (p=0.03). The model included the interaction between black race and time and adjusted for insurance status, risk factors (hypertension and diabetes), gender, age and prior stroke. Ina gender by race analysis, there was a trend towards black women being less likely to arrive earlier to the ED (HR 0.78, 95% CI 0.6 -1.0). However, overall, there was no race-ethnic interaction with arrival by EMS. CONCLUSIONS: Contrary to the perceived perception by the community suggesting there is a disparity in EMS utilization by the black DC community, we found no overall significant racial difference in EMS utilization for acute stroke. While there was a trend towards delayed overall arrival in black females, this was independent of EMS utilization.

Background and Purpose— Hypertension is the most important risk factor associated with intracerebral hemorrhage. We explored racial differences in blood pressure (BP) control after intracerebral hemorrhage and assessed predictors of BP control at presentation, 30 days, and 1 year in a prospective cohort study. Methods— Subjects with spontaneous intracerebral hemorrhage were identified from the DiffErenCes in the Imaging of Primary Hemorrhage based on Ethnicity or Race (DECIPHER) Project. BP was compared by race at each time point. Multivariable linear regression was used to determine predictors of presenting mean arterial pressure, and longitudinal linear regression was used to assess predictors of mean arterial pressure at follow-up. Results— A total of 162 patients were included (mean age, 59 years; 53% male; 77% black). Mean arterial pressure at presentation was 9.6 mm Hg higher in blacks than whites despite adjustment for confounders ( P =0.065). Fewer than 20% of patients had normal BP (P =0.331), blacks were more likely than whites to have Stage I/II hypertension at 1 year ( P =0.036). Factors associated with lower mean arterial pressure at follow-up in multivariable analysis were being married at baseline ( P =0.032) and living in a facility (versus personal residence) at the time of BP measurement ( P =0.023). Conclusions— Long-term BP control is inadequate in patients after intracerebral hemorrhage, particularly in blacks. Further studies are needed to understand the role of social support and barriers to control to identify optimal approaches to improve BP in this high-risk population.

Background: We have previously reported that approximately one-third of patients with primary intracerebral hemorrhage (ICH) have acute ischemic lesions remote from the hematoma on baseline and day 30 MR imaging. The objective of the current analysis was to determine the prevalence, characteristics, and associated risk factors for concurrent silent ischemic lesions at 1 year in a predominantly black, hypertensive ICH population. The analysis was undertaken as part of a prospective, multicenter, MRI-based, longitudinal natural history study of racial differences in patients with primary ICH. Methods: Inclusion criteria were: primary ICH, age ≥ 18, baseline and 1 year MRI scan obtained. Clinical and demographic data were collected on all subjects. A standardized MRI protocol was employed and included DWI (with apparent diffusion coefficient [ADC] maps), T2*-weighted image sequences (GRE), and FLAIR sequences. Images were evaluated for: location and volume of the primary hematoma, frequency and location of ischemic lesions, frequency and location of microbleeds, and white matter disease severity. DWI lesions were categorized as acute or subacute based on ADC maps. Results: Of the 104 patients with 1 year MRIs, mean age was 58 years, 55% were male, 76% black, and 87% had a history of hypertension. Primary hematoma location was deep in 77% of subjects and lobar in 23%. Mean baseline NIHSS was 8 (median 5). Mean baseline ICH volume was 20 cc (median 13 cc). DWI ischemic lesions were found in 18 (17%) subjects. Fifteen subjects had 1 lesion and 3 had 2 lesions. Of the total 21 lesions, 12 (57%) were acute (low ADC), and 9 (43%) were subacute. Nine (43%) lesions were located in lobar locations, and 12 (57%) were in deep structures. On univariate analysis, age, hypertension, prior stroke, microbleed burden, leukoaraiosis, antiplatelet use at 1 year, and mean arterial pressure at 1 year were not significantly associated with presence of DWI lesions. Conclusions: In this longitudinal MR imaging study of ICH, we found that 17% of subjects had evidence of ongoing silent ischemia on diffusion-weighted imaging at 1 year. This finding further supports the active nature of the underlying vasculopathy. A larger cohort is needed to identify risk factors for and/or imaging characteristics predictive of ischemic lesions. These lesions may be an important biomarker for future risk factor control.

Background: Performance on neurocognitive outcomes in patients with primary intracerebral hemorrhage (ICH) has not been well described, particularly in black populations. We sought to characterize neurocognitive performance at 30 days and 1 year in ICH patients enrolled in the DiffErenCes in the Imaging of Primary Hemorrhage based on Ethnicity or Race (DECIPHER) Project. Methods: Inclusion criteria were: primary ICH, age ≥ 18. Neurocognitive outcomes were assessed at 30 days, and 1 year. Domains assessed were: memory, executive function, verbal fluency, depression, and functional outcome. African American norms were used to establish cut-points. Independent t-tests were used to examine differences by race; paired t-tests were used to compare changes in performance between 30 days and 1 year, and p values were corrected for multiple comparisons. Results: Of 162 subjects enrolled, mean age was 59±13 years, 44% were female, 75% were black. Mean admission NIH Stroke Scale score was 9 (median 6). Neurocognitive outcomes were available for 142 subjects at 30 days and 100 subjects at 1 year. Significant impairment was observed for all domains at each interval: memory (30 days 88%, 1 year 84%); verbal fluency (30 days 84%, 1 year 84%); attention (30 days 51%, 1 year 49%), and executive function (30 days 52%, 1 year 51%). Depression was observed in 44% at 30 days and 38% at 1 year. Functional impairment (mRS > 2) was found in 46% at 30 days and 40% at 1 year. Twenty one percent screened positive for dementia at 30 days and 13% at 1 year. Blacks had significantly lower scores at 30 days for memory (p Conclusions: Significant impairments in all neurocognitive domains were observed at both 30 days and 1 year in this population of ICH subjects. Blacks had greater cognitive impairment and less depression at 30 days, however, these differences were no longer present at 1 year. While performance improved over time, significant impairment in memory, attention, fluency, and executive function persisted at 1 year.

Introduction: The impact of acute perihematomal edema (PHE) as an independent predictor of clinical outcomes following an intracerebral hemorrhage (ICH) has been controversial. To date, some studies have reported that PHE is associated with poorer outcomes, while others have found an association with good outcomes. The goals of the current analysis were to 1) identify predictors of acute PHE, and 2) determine impact of PHE on clinical outcomes in a predominantly African American hypertensive ICH population. Methods: Subjects with spontaneous non-traumatic ICH who were prospectively enrolled in the DiffErenCes in the Imaging of Primary Hemorrhage based on Ethnicity or Race (DECIPHER) Project were included in the analysis. Baseline MRIs were performed in subjects at median of 2 days from onset. Hematoma volume as well as PHE were calculated from GRE and FLAIR sequences, respectively, employing a semiautomated volumetric analysis. PHE volume was expressed as a percent of the hematoma volume (PHEv/ICHv x 100). Outcome measures included year 1 NIHSS score using a log-linear model and dichotomized (0-2 vs. 3-6) modified Rankin Scale (mRS) using a logistic regression model. Results: A total of 140 subjects were included in the analysis. Mean age was 59, 58% were male, 75% were black, and 85% had a history of hypertension. Baseline NIHSS score was mean 9 (median 6), mean ICH volume was 25 cc (range 0.5-136 cc), and mean relative PHE percent was 115% (range 0-559%). Independent predictors of PHE on multivariate analysis included ICH volume (p=0.004) and antiplatelet use on admission (p=0.02). At the year 1 timepoint, there was no significant association between the severity of PHE percent and good or poor outcome based on dichotomized mRS (p=0.67); however there was a modest trend towards an association between increased edema and lower NIHSS scores (p=0.15). Conclusions: In this large MRI-based cohort of patients with primary ICH, acute perihematomal edema measured on FLAIR sequences was not an independent predictor of poor functional outcome at year 1 employing the mRS. However, there was a modest trend towards an association between increased relative edema volume and lower year 1 NIHSS scores, which may suggest a protective effect of edema on outcome. Further studies in a larger cohort are needed to clarify the impact of both acute and peak perihematomal edema on outcome following primary ICH.

Background: Among patients with ischemic stroke, a link between chronic kidney disease (CKD) and presence of MRI-defined cerebral microbleeds (CMB), a harbinger of future hemorrhagic stroke, has been reported. However, the association of CKD with CMB among patients with intracerebral hemorrhage (ICH) has not been systematically investigated. The objective of this analysis was to evaluate the relationship between CKD and CMB in a biracial cohort of patients with ICH. Methods: Using data from subjects with a recent ICH enrolled in a NIH-sponsored observational study between September 2007, and June 2011, we evaluated the association between CKD (defined as estimated low glomerular filtration rate (GFR) 2 ) and CMB. The number and location of CMBs were identified on gradient-echo T2*-weighted magnetic resonance imaging. Multivariable models were generated to determine the contribution of CKD to the presence, number, and location of CMB after adjusting for confounders (age, sex, systolic BP, history of hypertension, antihypertensive drug use, and diabetes). Results: Of 162 subjects with complete data, mean age was 59 years, 44% were female, 74% were Black, 97 (60%) had 1 or more CMBs and 47 (29%) had CKD. In univariate analyses, subjects with CKD differed from those without CKD (p Conclusions: CKD is associated with presence, number and location of CMB in ICH patients. These relationships are more pronounced in Black compared to Non-Hispanic White ICH patients. Low GFR may be a CMB risk marker or potential therapeutic target for mitigating the development of CMB. Further investigation is required to see if RAS modulators may have a role to play in ameliorating CMB occurrence.

Objective: Hypertension is the most important risk factor for both primary and secondary prevention of intracerebral hemorrhage (ICH). We sought to determine the frequency of blood pressure control after ICH and explored predictors of higher blood pressure (BP) at presentation, 30 days, and 1 year in a prospective cohort study. Methods: Individuals with spontaneous non-traumatic ICH were prospectively enrolled in the DiffErenCes in the Imaging of Primary Hemorrhage based on Ethnicity or Race (DECIPHER) Project. BP was measured at 30 days and 1 year during in-person visits, and BP at presentation was abstracted from the medical record. Linear regression was used to determine factors associated with mean arterial pressure (MAP) at presentation, and longitudinal linear regression was used to determine baseline predictors of MAP at 30 days at 1 year. Results: A total of 143 patients had blood pressure data available at either 30 days (125 patients) or 1 year (85 patients). Mean age was 59, 57% were men, and 80% were African American (AA) and the rest were White (other race/ethnic groups excluded due to low numbers). AAs were younger (57 vs. 65, p=0.002), less likely to be married (37% vs. 61%, p=0.02), more likely to have a history of hypertension (90% vs. 71%, p=0.03), and more likely to be smokers (30% vs. 11%, p=0.03) than Whites. Average BP at presentation was 178±35/99±24mmHg. Multivariable linear regression revealed that AAs had a presenting MAP that was on average 14mmHg higher than Whites despite adjustment for age, gender, socioeconomic status, body mass index, private health insurance, marital status, smoking, cocaine, and ICH volume. Blood pressure control at follow-up was poor, with fewer than 20% of patients having a normal blood pressure ( Conclusions: AAs had a higher MAP than Whites at the time of presentation with ICH. Optimal blood pressure control at 1 year occurred in less than 20% of the cohort. The only factor predictive of lower MAP at follow up was being married at baseline. Additional efforts are urgently needed to improve blood pressure control in both AA and White ICH survivors.

BACKGROUND: Lack of culturally appropriate education about stroke may prevent people from recognizing symptoms and/or seeking immediate care. The Stroke Warning Information and Faster Treatment (SWIFT) intervention reports increasing the proportion of prevalent stroke/TIA cases arriving under 4.5 hours using culturally tailored strategies, but few interventions have rigorously evaluated preparedness strategies in community settings. ASPIRE is a multi-dimensional program with a three-pronged approach (community, hospital, EMS) to acute stroke preparedness targeted to increased IV tPA utilization in underserved black communities in the DC metro area. METHODS: Using community engaged methodology, a skill-based approach to teaching community members to recognize acute stroke, call 911 and navigate the ER setting was developed. In the pilot phase, 50 education sessions were conducted in church, civic, educational and work organizations over a six month period in Ward 7 of the DC Metro area. Local ER and EMS staff were also in-serviced. We prospectively identified all hospital stroke admissions and EMS utilization information including acute stroke parameters for the 6 month pre and post intervention periods. Pre-post pilot intervention acute ischemic stroke parameters were compared. RESULTS: In the pre-intervention period, we identified 142 ischemic strokes in Ward 7: mean age 63 yrs; 63% male; 96% blacks. Fifty-six percent arrived via EMS, with a mean and median time to arrival of 1600 minutes (27.0 hours), and 890 minutes (14.8 hours), respectively. Following the intervention we identified 115 ischemic stroke cases: 66 yrs; 47% male; 89% black. Fifty percent arrived via EMS, mean and median time to arrival was 1423 min (23.7 hours) and 815 min (13.6 hours). In addition to this modest decrease in overall arrival times, an increased proportion of cases arriving in the 4.5 hours group was noted [pre 25% vs. post 28%, p=NS]. We were also able to match 104 ischemic stroke cases to EMS utilization sheets demonstrating feasibility for larger evaluation. CONCULSION: The ASPIRE pilot demonstrates feasibility of the multilevel community education intervention as well as feasibility of linking EMS and hospital records on a city wide scale. Despite the small number of ischemic strokes in this pilot phase, a modest reduction in hospital arrival times occurred in the post intervention phase. A city-wide intervention aimed at increasing the proportion of stroke patients treated with IV tPA is currently underway.

Introduction: Cerebral microbleeds (MBs) have emerged as a marker for a hemorrhage-prone vasculopathy. Few studies have evaluated MBs prospectively following intracerebral hemorrhage (ICH). We sought to investigate the frequency of rapid MB development in a predominantly African-American hypertensive ICH population. Methods: The Differences in the Imaging of Primary Hemorrhage Based on Ethnicity or Race (DECIPHER) study is an ongoing prospective, longitudinal, MR-based cohort study designed to evaluate racial/ethnic differences in risk factors for MBs and to prospectively evaluate the prognostic impact of MBs in underserved patients with ICH. We evaluated new MB formation in 2 time periods: from baseline to 30-day and from 30-day to 1-year. All 30-day images were coregistered to the baseline images in the first analysis; 1-year images were coregistered to 30-day images in the second. MB presence and location were determined by consensus review. Only subjects with 3T GRE sequences were included in this analysis. Univariate analyses were performed for both time intervals and subsequent logistic regression analysis was performed on the 30-day to 1-year analysis with new MB formation as the outcome variable. Results: Of the 35 subjects in the baseline to 30-day analysis, 7 (20%) had new MBs, compared to 20 of 55 (36%) in the 30-day to 1-year analysis. Univariate analyses are shown in the Table . Primary ICH location was deep in 32/35 (91%) in the first analysis and in 35/47 (74%) in the second. ApoE status, CAD, smoking status, and atrial fibrillation were not significantly different in either analysis. Logistic regression analysis demonstrated that MAP was significantly associated with new MB formation (OR 1.04 [95% CI 1.0, 1.07], p=0.038); a protective effect of hyperlipidemia was non-significant (OR 0.256, p=0.116). Conclusions: Despite a relatively small sample size, we found that more than one-third of ICH patients surviving one year developed new MBs, which suggests a dynamic and rapidly progressive vasculopathy at work. Future studies will examine the impact of new MB formation on patient outcomes.

Background and Purpose— Some prior studies have shown that racial disparities exist in intravenous tissue plasminogen activator (tPA) use for acute ischemic stroke. We sought to determine whether race was associated with tPA treatment for stroke in a predominantly black urban population. Methods— Systematic chart abstraction was performed on consecutive hospitalized patients with ischemic stroke from all 7 acute care hospitals in the District of Columbia from February 1, 2008, to January 31, 2009. Results— Of 1044 patients with ischemic stroke, 74% were black, 19% non-Hispanic white, and 5% received intravenous tPA. Blacks were one third less likely than whites to receive intravenous tPA (3% versus 10%, P P =0.004) and also less likely to be tPA-eligible (5% versus 13%, P P =0.023). The treatment rate for tPA-eligible patients was similar for blacks and whites (70% versus 76%, P =0.62). Conclusions— In this predominantly black urban population hospitalized for acute ischemic stroke, blacks were significantly less likely to be treated with intravenous tPA due to contraindications to treatment, delayed presentation, and stroke severity. Effective interventions designed to increase treatment in this population need to focus on culturally relevant education programs designed to address barriers specific to this population.

Background and Purpose— Stroke incidence and prevalence estimates in developing countries should include stroke cases not presenting to hospital. We performed door-to-door stroke case ascertainment in Durango Municipality, Mexico, to estimate stroke incidence and prevalence and to determine the error made by only ascertaining hospital cases. Methods— Between September 2008 and March 2009, 1996 housing units were randomly sampled to screen for stroke in Durango Municipality residents 35 years of age and older. Field workers utilized a validated screening tool. Those screening positive were referred to a neurologist for history and examination and a head CT scan. Prevalence and cumulative incidence from the door-to-door surveillance were calculated and compared with previously reported hospitalization rates during the same defined time. Results— Respondents included 2437 subjects from 1419 homes. The refusal rate was 3.8%. Twenty subjects had verified or probable stroke. The prevalence of probable or verified stroke was 7.7 per 1000 (95% CI, 4.3 per 1000–11.2 per 1000). Five patients had a stroke during the time of the hospital surveillance, yielding a cumulative incidence of 232.3 per 100 000 (95% CI, 27.8–436.9). Two of the 5 cases were captured by door-to-door surveillance but not by hospital surveillance. Conclusions— This study provides the first community-based stroke prevalence and incidence estimates in Mexico. The wide confidence intervals, despite the large number of surveyed housing units, suggest the need for more advanced sampling strategies for stroke surveillance in the developing world.