Search

Background: We evaluated the effect of persistent hyperglycemia on outcomes in 1000 patients with intracerebral hemorrhage enrolled within 4.5 hours of symptom onset. Methods: We defined moderate and severe hyperglycemia based on serum glucose levels ≥140 mg/dL— Results: In the multivariate analysis, both moderate (odds ratio, 1.8 [95% CI, 1.1–2.8]) and severe (odds ratio, 1.8 [95% CI, 1.2–2.7]) hyperglycemia were associated with higher 90-day death or disability after adjusting for Glasgow Coma Scale score, hematoma volume, presence or absence of intraventricular hemorrhage, hyperlipidemia, cigarette smoking, and hypertension (no interaction between hyperglycemia and preexisting diabetes, P =0.996). Among the patients without preexisting diabetes, both moderate (odds ratio, 1.8 [95% CI, 1.0–3.2]) and severe (odds ratio, 2.0 [95% CI, 1.1–3.7]) hyperglycemia were associated with 90-day death or disability after adjusting for above mentioned potential confounders. Among the patients with preexisting diabetes, moderate and severe hyperglycemia were not associated with 90-day death or disability. Conclusions: Persistent hyperglycemia, either moderate or severe, increased the risk of death or disability in nondiabetic patients with intracerebral hemorrhage. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01176565.

ObjectiveTo summarise evidence of the effects of blood pressure (BP)-lowering interventions after acute spontaneous intracerebral haemorrhage (ICH).MethodsA prespecified systematic review of the Cochrane Central Register of Controlled Trials, EMBASE and MEDLINE databases from inception to 23 June 2020 to identify randomised controlled trials that compared active BP-lowering agents versus placebo or intensive versus guideline BP-lowering targets for adults 6 mL) and proportional (>33%) haematoma growth at 24 hours. Meta-analysis used a one-stage approach, adjusted using generalised linear mixed models with prespecified covariables and trial as a random effect.ResultsOf 7094 studies identified, 50 trials involving 11 494 patients were eligible and 16 (32.0%) shared patient-level data from 6221 (54.1%) patients (mean age 64.2 [SD 12.9], 2266 [36.4%] females) with a median time from symptom onset to randomisation of 3.8 hours (IQR 2.6–5.3). Active/intensive BP-lowering interventions had no effect on the primary outcome compared with placebo/guideline treatment (adjusted OR for unfavourable shift in modified Rankin scale scores: 0.97, 95% CI 0.88 to 1.06; p=0.50), but there was significant heterogeneity by strategy (pinteraction=0.031) and agent (pinteraction6 ml, adjusted OR 0.75, 95%CI 0.60 to 0.92; p=0.0077) and relative (≥33%, adjusted OR 0.82, 95%CI 0.68 to 0.99; p=0.034) haematoma growth.InterpretationOverall, a broad range of interventions to lower BP within 7 days of ICH onset had no overall benefit on functional recovery, despite reducing bleeding. The treatment effect appeared to vary according to strategy and agent.PROSPERO registration numberCRD42019141136.

Background: It is unknown if race/ethnicity modifies the response to blood pressure (BP) lowering treatment after intracerebral hemorrhage (ICH). We aimed to examine the race/ethnicity differences in the response to BP lowering treatment after ICH. Methods: This is a post hoc analysis of the Antihypertensive Treatment of Acute Cerebral Hemorrhage II (ATACH-2) trial. The primary outcome is good outcome, defined as 90-day modified Rankin Scale 0–3. The primary predictor is race/ethnicity for which we included non-Hispanic categories of White, Black, Asian, and the category of Hispanic. We fit adjusted logistic regression models with the predictor of race/ethnicity and models with the interaction term of treatment*race/ethnicity. Results: We included a total of 953 patients in our analysis (White = 213, Black = 112, Asian = 554, and Hispanic = 74). In the models with the interaction between race/ethnicity and treatment, we found that White patients assigned to the intensive treatment arm had lower predicted probability of good outcome than those assigned to the standard treatment arm (Model 1: 56.2% vs. 68.1%, p = .027; Model 2: 53.4% vs. 68.3%, p = .009). When divided into White and non-White groups, intensive treatment was associated with higher odds of serious adverse events in White group but not in the non-White group. In addition, there was an association between intensive treatment and higher risk of hematoma expansion in White patients and lower risk of hematoma expansion in non-White patients. Conclusions: In the ATACH-2, there was an interaction between race/ethnicity and response to BP lowering treatment after ICH, with White patients having an association between intensive blood pressure reduction and worse outcome.

Background and aims Nicardipine has strong, rapidly acting antihypertensive activity. The effects of acute systolic blood pressure levels achieved with intravenous nicardipine after onset of intracerebral hemorrhage on clinical outcomes were determined. Methods A systematic review and individual participant data analysis of articles before 1 October 2020 identified on PubMed were performed (PROSPERO: CRD42020213857). Prospective studies involving hyperacute intracerebral hemorrhage adults treated with intravenous nicardipine whose outcome was assessed using the modified Rankin Scale were eligible. Outcomes included death or disability at 90 days, defined as the modified Rankin Scale score of 4–6, and hematoma expansion, defined as an increase ≥6 mL from baseline to 24-h computed tomography. Summary of review Three studies met the eligibility criteria. For 1265 patients enrolled (age 62.6 ± 13.0 years, 484 women), death or disability occurred in 38.2% and hematoma expansion occurred in 17.4%. Mean hourly systolic blood pressure during the initial 24 h was positively associated with death or disability (adjusted odds ratio (aOR) 1.12, 95% confidence interval (CI) 1.00–1.26 per 10 mmHg) and hematoma expansion (1.16, 1.02–1.32). Mean hourly systolic blood pressure from 1 h to any timepoint during the initial 24 h was positively associated with death or disability. Later achievement of systolic blood pressure to ≤140 mmHg increased the risk of death or disability (aOR 1.02, 95% CI 1.00–1.05 per hour). Conclusions Rapid lowering of systolic blood pressure by continuous administration of intravenous nicardipine during the initial 24 h in hyperacute intracerebral hemorrhage was associated with lower risks of hematoma expansion and 90-day death or disability without increasing serious adverse events.

Objective To investigate whether significant differences exist in recanalization rates and primary outcomes between patients who undergo mechanical thrombectomy alone versus those who undergo mechanical thrombectomy with acute intracranial stenting. Methods Through the utilization of a prospectively collected endovascular database at a comprehensive stroke center between 2012 and 2020, variables such as demographics, co-morbid conditions, symptomatic intracerebral hemorrhage, mortality rate at discharge, and good/poor outcomes in regard to modified thrombolysis in cerebral infarction score and modified Rankin Scale were examined. The outcomes between patients receiving acute intracranial stenting + mechanical thrombectomy and patients that underwent mechanical thrombectomy alone were compared. Results There were a total of 420 acute ischemic stroke patients who met criteria for the study (average age 70.6 ± 13.01 years; 46.9% were women). Analysis of 46 patients from the acute stenting + mechanical thrombectomy group (average age 70.34 ± 13.75 years; 37.0% were women), and 374 patients from the mechanical thrombectomy alone group (average age 70.64 ± 12.92 years; 48.1% were women). Four patients (8.7%) in the acute stenting + mechanical thrombectomy group experienced intracerebral hemorrhage versus 45 patients (12.0%) in the mechanical thrombectomy alone group ( p = 0.506); no significant increases were noted in the median length of stay (7 vs 8 days; p = 0.208), rates of modified thrombolysis in cerebral infarction 2B-3 recanalization ( p = 0.758), or good modified Rankin Scale scores ( p = 0.806). Conclusion Acute intracranial stenting in addition to mechanical thrombectomy was not associated with an increase in overall length of stay, intracerebral hemorrhage rates, or any change in discharge modified Rankin Scale. Further research is required to determine whether mechanical thrombectomy and acute intracranial stenting in acute ischemic stroke patients is unsafe.

Background and purpose We report the results of intra-arterial injection of lidocaine in the middle meningeal artery in patients with intractable headache or status migrainosus. Methods We treated four patients with intra-arterial lidocaine (2 mg/ml) in doses up to 50 mg in each middle meningeal artery via a microcatheter bilaterally (except in one patient). In two patients with intractable headache, the daily maximum intensity of headache (graded by 11-point numeric rating scale) was recorded for 7 days postprocedure. In two patients with status migrainosus, migraine-related disability 3 months prior and after treatment using MIDAS (Migraine Disability Assessment) questionnaire was recorded. Results Intra-arterial lidocaine reduced the headache intensity from 8/10 and 10/10 to 0/10 in the two patients with intractable headaches for 2 days (day 0 and day 1) postprocedure. Despite recurrence of headache on day 2, the intensity was less than preprocedure intensity up to the last day recorded (by 3 and 2 points on day 7). In the two patients with status migrainosus, there was immediate reduction in headache intensity following intra-arterial lidocaine. The post treatment 3-month MIDAS score was lower in both patients compared with pretreatment 3-month score; 3 versus 30 and 55 versus 90. Severe disability preprocedure by MIDAS was reduced to little or no disability postprocedure in one patient. Conclusions Intra-arterial lidocaine resulted in amelioration of headache in patients with intractable headache and those with status migrainosus with improvement lasting longer than the short half-life of lidocaine possibly related to central desensitization.

With the increasing use of magnetic resonance imaging in the assessment of acute intracerebral hemorrhage, diffusion-weighted imaging hyperintense lesions have been recognized to occur at sites remote to the hematoma in up to 40% of patients. We investigated whether blood pressure reduction was associated with diffusion-weighted imaging hyperintense lesions in acute intracerebral hemorrhage and whether such lesions are associated with worse clinical outcomes by analyzing imaging data from a randomized trial. We performed exploratory subgroup analyses in an open-label randomized trial that investigated acute blood pressure lowering in 1000 patients with intracerebral hemorrhage between May 2011 and September 2015. Eligible participants were assigned to an intensive systolic blood pressure target of 110–139 mm Hg versus 140–179 mm Hg with the use of intravenous nicardipine. Of these, 171 patients had requisite magnetic resonance imaging sequences for inclusion in these subgroup analyses. The primary outcome was the presence of diffusion-weighted imaging hyperintense lesions. Secondary outcomes included death or disability and serious adverse event at 90 days. Diffusion-weighted imaging hyperintense lesions were present in 25% of patients (mean age 62 years). Hematoma volume > 30 cm3 was an adjusted predictor (adjusted relative risk 2.41, 95% confidence interval 1.00–5.80) of lesion presence. Lesions occurred in 25% of intensively treated patients and 24% of standard treatment patients (relative risk 1.01, 95% confidence interval 0.71–1.43, p = 0.97). Patients with diffusion-weighted imaging hyperintense lesions had similar frequencies of death or disability at 90 days, compared with patients without lesions. Randomized assignment to intensive acute blood pressure lowering did not result in a greater frequency of diffusion-weighted imaging hyperintense lesion. Alternative mechanisms of diffusion-weighted imaging hyperintense lesion formation other than hemodynamic fluctuations need to be explored. Clinical trial registration ClinicalTrials.gov (Ref. NCT01176565; https://clinicaltrials.gov/ct2/show/NCT01176565 ).

BACKGROUND AND PURPOSE Radiomics provides a framework for automated extraction of high-dimensional feature sets from medical images. We aimed to determine radiomics signature correlates of admission clinical severity and medium-term outcome from intracerebral hemorrhage (ICH) lesions on baseline head computed tomography (CT). METHODS We used the ATACH-2 (Antihypertensive Treatment of Acute Cerebral Hemorrhage II) trial dataset. Patients included in this analysis (n = 895) were randomly allocated to discovery (n = 448) and independent validation (n = 447) cohorts. We extracted 1130 radiomics features from hematoma lesions on baseline noncontrast head CT scans and generated radiomics signatures associated with admission Glasgow Coma Scale (GCS), admission National Institutes of Health Stroke Scale (NIHSS), and 3-month modified Rankin Scale (mRS) scores. Spearman's correlation between radiomics signatures and corresponding target variables was compared with hematoma volume. RESULTS In the discovery cohort, radiomics signatures, compared to ICH volume, had a significantly stronger association with admission GCS (0.47 vs. 0.44, p = 0.008), admission NIHSS (0.69 vs. 0.57, p

Objective: To identify differences in short-term outcomes of patients with coronavirus disease 2019 (COVID-19) according to various racial/ethnic groups. Design: Analysis of Cerner de-identified COVID-19 dataset. Setting: A total of 62 health care facilities. Participants: The cohort included 49,277 adult COVID-19 patients who were hospitalized from December 1, 2019 to November 13, 2020. Methods: We compared patients’ age, gender, individual components of Charl­son and Elixhauser comorbidities, medical complications, use of do-not-resuscitate, use of palliative care, and socioeconomic status between various racial and/or ethnic groups. We further compared the rates of in-hos­pital mortality and non-routine discharges between various racial and/or ethnic groups. Main Outcome Measures: The primary outcome of interest was in-hospital mortali­ty. The secondary outcome was non-routine discharge (discharge to destinations other than home, such as short-term hospitals or other facilities including intermediate care and skilled nursing homes). Results: Compared with White patients, in-hospital mortality was significantly higher among African American (OR 1.5; 95%CI:1.3-1.6, P

Background and ObjectiveThe clinical effect of renal impairment on intracerebral hemorrhage (ICH) is unknown. This study sought to assess whether estimated glomerular filtration rate (eGFR) affects clinical outcomes or modifies the efficacy of intensive systolic blood pressure (BP) control (target, 110–139 mm Hg) against the standard (target, 140–179 mm Hg) among patients with ICH.MethodsWe conducted post hoc analyses of ATACH-2, a randomized, 2-group, open-label trial. The baseline eGFR of each eligible patient was calculated using the Chronic Kidney Disease Epidemiology Collaboration equation. The outcome of interest was death or disability at 90 days. Multivariate logistic regression models were used for analysis.ResultsAmong the 1,000 patients randomized, 974 were analyzed. The median baseline eGFR was 88 (interquartile range, 68, 99) mL/min/1.73 m2; 451 (46.3%), 363 (37.3%), and 160 (16.4%) patients had baseline eGFR values of ≥90, 60–89, and 2, respectively. Compared with normal eGFR (≥90 mL/min/1.73 m2), higher odds of death or disability were noted among those with eGFR values of 2(adjusted odds ratio [OR], 2.02; 95% confidence interval [CI], 1.25–3.26) but not among those with eGFR values of 60–89 mL/min/1.73 m2(OR, 1.01; 95% CI, 0.70–1.46). The odds of death or disability were significantly higher in the intensive arm among patients with decreased eGFR; the ORs were 0.89 (95% CI, 0.55–1.44), 1.13 (0.68–1.89), and 3.60 (1.47–8.80) in patients with eGFR values of ≥90, 60–89, and 2, respectively (pfor interaction = 0.02).DiscussionDecreased eGFR is associated with unfavorable outcomes following ICH. The statistically significant interaction between the eGFR group and treatment assignment raised safety concerns for the intensive BP-lowering therapy among patients with renal impairment.Trial Registration InformationClinicaltrials.gov identifier:NCT01176565.Classification of EvidenceThis study provides Class II evidence that in spontaneous ICH, decreased eGFR identifies patients at risk of death or disability following intensive BP control.

ObjectiveTo identify the beneficial effects of thrombectomy capable hospitals (TCHs), by comparing the incidence of in-hospital adverse events and discharge outcomes among patients with ischemic stroke treated at thrombectomy capable and non-thrombectomy capable hospitals in the United States.MethodsWe used the data from the Nationwide Inpatient Sample from January 2012 to December 2017. Thrombectomy capable hospitals were identified based on the number of thrombectomy procedures performed by a hospital each year among patients with ischemic stroke. If a hospital performed 10 or more thrombectomy procedures, it was labelled a TCH. The inclusion criteria were age ≥18 years, and ischemic stroke (International Classification of Diseases 433 .x1-434.x1 (ICD-9) or I63 (ICD-10)) as primary discharge diagnosis. A comparative analysis of propensity-matched patient groups was done to study the influence of TCH admissions on in-hospital outcomes.ResultsA total of 2 826 334 patients with primary ischemic stroke were identified. In a multivariate logistic regression model after adjusting for age, sex, race/ethnicity, hospital teaching status, comorbidities, and all patients refined diagnosis-related groups-based disease severity, patients admitted to a TCH were found to have low incidence of in-hospital adverse events: pneumonia (OR=0.86, 95% CI 0.78 to 0.93), urinary tract infection (OR=0.87, 95% CI 0.84 to 0.91), sepsis (OR=0.91, 95% CI 0.81 to 1.02), and pulmonary embolism (OR=0.89, 95% CI 0.77 to 1.03); in-hospital death (OR=0.82, 95% CI 0.78 to 0.88); and higher rate of home discharge (OR=1.09, 95% CI 1.06 to 1.12).ConclusionsA decrease in-hospital adverse events and improved discharge outcomes were observed among patients with ischemic stroke admitted to a TCH compared with a non-TCH.

Background A better understanding of reinfection after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has become one of the healthcare priorities in the current pandemic. We determined the rate of reinfection, associated factors, and mortality during follow-up in a cohort of patients with SARS-CoV-2 infection. Methods We analyzed 9119 patients with SARS-CoV-2 infection who received serial tests in total of 62 healthcare facilities in the United States between 1 December 2019 and 13 November 2020. Reinfection was defined by 2 positive tests separated by interval of >90 days and resolution of first infection was confirmed by 2 or more consecutive negative tests. We performed logistic regression analysis to identify demographic and clinical characteristics associated with reinfection. Results Reinfection was identified in 0.7% (n = 63, 95% confidence interval [CI]: .5%–.9%) during follow-up of 9119 patients with SARS-CoV-2 infection. The mean period (±standard deviation [SD]) between 2 positive tests was 116 ± 21 days. A logistic regression analysis identified that asthma (odds ratio [OR] 1.9, 95% CI: 1.1–3.2) and nicotine dependence/tobacco use (OR 2.7, 95% CI: 1.6–4.5) were associated with reinfection. There was a significantly lower rate of pneumonia, heart failure, and acute kidney injury observed with reinfection compared with primary infection among the 63 patients with reinfection There were 2 deaths (3.2%) associated with reinfection. Conclusions We identified a low rate of reinfection confirmed by laboratory tests in a large cohort of patients with SARS-CoV-2 infection. Although reinfection appeared to be milder than primary infection, there was associated mortality.

Background and Purpose: Acute ischemic stroke may occur in patients with coronavirus disease 2019 (COVID-19), but risk factors, in-hospital events, and outcomes are not well studied in large cohorts. We identified risk factors, comorbidities, and outcomes in patients with COVID-19 with or without acute ischemic stroke and compared with patients without COVID-19 and acute ischemic stroke. Methods: We analyzed the data from 54 health care facilities using the Cerner deidentified COVID-19 dataset. The dataset included patients with an emergency department or inpatient encounter with discharge diagnoses codes that could be associated to suspicion of or exposure to COVID-19 or confirmed COVID-19. Results: A total of 103 (1.3%) patients developed acute ischemic stroke among 8163 patients with COVID-19. Among all patients with COVID-19, the proportion of patients with hypertension, diabetes, hyperlipidemia, atrial fibrillation, and congestive heart failure was significantly higher among those with acute ischemic stroke. Acute ischemic stroke was associated with discharge to destination other than home or death (relative risk, 2.1 [95% CI, 1.6–2.4]; P P =0.03) after adjusting for potential confounders. Conclusions: Acute ischemic stroke was infrequent in patients with COVID-19 and usually occurs in the presence of other cardiovascular risk factors. The risk of discharge to destination other than home or death increased 2-fold with occurrence of acute ischemic stroke in patients with COVID-19.

Objective:To compare the impact of intensive blood pressure (BP) lowering right after intracerebral hemorrhage (ICH) on clinical and hematoma outcomes among patients from different geographic locations, we performed a prespecified sub-analysis of the randomized, multi-national, two-group, open-label trial to determine the efficacy of rapidly lowering BP in hyperacute ICH (ATACH-2), involving 537 patients from East Asia and 463 recruited outside of Asia.Methods:Eligible patients were randomly assigned to a systolic BP (SBP) target of 110-139 mmHg (intensive treatment) or 140-179 mmHg (standard treatment). Pre-defined outcomes were: poor functional outcome (modified Rankin Scale score of 4-6 at 90 days), death within 90 days, hematoma expansion at 24 hours; and cardio-renal adverse events within 7 days.Results:Poor functional outcomes (32.0% versus 45.9%), death (1.9% versus 13.3%), and cardio-renal adverse events (3.9% versus 11.2%) occurred significantly less in patients from Asia than those outside of Asia. The treatment-by-cohort interaction was not significant for any outcomes. Only patients from Asia showed a lower incidence of hematoma expansion with intensive treatment (adjusted RR 0.56, 95% CI 0.38-0.83). Both Asian (3.53, 1.28-9.64) and non-Asian cohorts (1.71, 1.00-2.93) showed a higher incidence of cardio-renal adverse events with intensive treatment.Conclusions:Poor functional outcomes and death 90 days after ICH were less common in patients from East Asia than those outside of Asia. Hematoma expansion, a potential predictor for poor clinical outcome, was attenuated by intensive BP lowering only in the Asian cohort.Clinicaltrials.gov identifierNCT01176565.Classification of evidence:This study provides Class II evidence that, for patients from East Asia with intracerebral hemorrhage, intensive blood pressure lowering significantly reduces the risk of hematoma expansion.

Background Spinal arachnoid webs are a rare anatomic entity manifesting as neuropathic back pain, compressive myelopathy, radiculopathy and hydrocephalus. Typical treatments include hemi or full laminectomy with durotomy and microsurgical resection which can result in secondary scarring, and recurrent blockage of cerebrospinal fluid flow perpetuating the cycle. Case Description A 66-year-old woman presented with progressively worsening gait and memory. Magnetic resonance imaging (MRI) demonstrated an arachnoid web in the high thoracic region, causing cerebrospinal fluid flow obstruction and hydrocephalus. A standard lumbar drainage catheter was introduced percutaneously into the lumbar thecal sac, and advanced in a cephalad direction, across the arachnoid web, to the high thoracic region. The patient underwent continuous cerebrospinal fluid drainage through this catheter for a total of three days, displaying measurable clinical improvement that persisted at the three months follow up visit. Phase-contrast MRI demonstrated interval reconstitution of dorsal synchronous cerebrospinal fluid flow at the 2nd thoracic vertebral level, both on day three, as well as at the three months control imaging study. Conclusion This minimally invasive approach seems useful in achieving restoration of spinal fluid flow at the thoracic region when the underlying blockage results from an arachnoid web and leads to quantifiable clinical improvement.

Background and Purpose: Evidence regarding sex differences in clinical outcomes and treatment effect following intracerebral hemorrhage is limited. Using the ATACH-2 trial (Antihypertensive Treatment in Intracerebral Hemorrhage-2) data, we explored whether sex disparities exist in outcomes and response to intensive blood pressure (BP)–lowering therapy. Methods: Eligible intracerebral hemorrhage subjects were randomly assigned to intensive (target systolic BP, 110–139 mm Hg) or standard (140–179 mm Hg) BP-lowering therapy within 4.5 hours after onset. Relative risk of death or disability corresponding to the modified Rankin Scale score of 4 to 6 was calculated, and interaction between sex and treatment was explored. Results: In total, 380 women and 620 men were included. Women were older, more prescribed antihypertensive drugs before onset, and had more lobar intracerebral hemorrhage than men. Hematoma expansion was observed less in women. After multivariable adjustment, the relative risk of death or disability in women was 1.19 (95% CI, 1.02–1.37, P =0.023). The relative risk of death or disability between intensive versus standard BP-lowering therapy was 0.91 (95% CI, 0.74–1.13) in women versus 1.13 (95% CI, 0.92–1.39) in men ( P for interaction=0.11), with inconclusive Gail-Simmon test ( P =0.16). Conclusions: Women had a higher risk of death or disability following intracerebral hemorrhage. The benefit of intensive BP-lowering therapy in women is inconclusive, consistent with the overall results of ATACH-2. Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT01176565.

Background and purpose Due to higher rates of 1-month stroke and death with Wingspan intracranial stent placement observed in SAMMPRIS, the Food and Drug Administration (FDA) announced a more limited indication for Wingspan stent. Methods We compared the results of intracranial stent placement with best medical treatment in patients recruited in SAMMPRIS who met the new "on label" criteria with those who were categorized as "off label." The primary endpoint was any stroke or death occurring within 30 days of enrollment, or an ischemic stroke in the territory of the symptomatic intracranial artery from day 31 after study entry to completion of follow-up. Results A total of 31 (7%) among 451 recruited patients met the "on label" criteria. The relative risk of primary endpoint was lower in "on label" patients treated with stent placement compared with best medical treatment (relative risk .61, 95% confidence interval .2-1.7) but higher in "off label" patients (relative risk 1.81, 95% confidence interval 1.2-2.6). Primary endpoint was seen in 20% and 23.4% of patients treated with stent placement in "on label" and "off label" patients, respectively. Primary endpoint was seen in 25% and 14.2% of patients treated with best medical treatment in "on label" and "off label" patients, respectively. Conclusion The new FDA "on label" criteria may identify a small group of people, who may benefit from intracranial stent placement due to higher risk of primary endpoint in those treated with best medical treatment.

Carotid endarterectomy (CEA) and carotid artery stenting (CAS) have been well-established as two effective treatment modalities for carotid artery stenosis, while their clinical outcomes in real-world China are still unknown due to lack of nationwide trials. We aimed to evaluate the safety outcome profile of CEA and CAS in Chinese patients with carotid artery stenosis. The Revascularization of Extracranial Carotid Artery Stenosis trial was a multicentre, prospective cohort study of CEA or CAS in treating patients with carotid artery stenosis. We included symptomatic or asymptomatic patients with carotid artery stenosis (≥ 50%). The primary endpoint was any stroke, myocardial infarction and/or death within 1 month post-procedure. Overall, 2719 cases (1543 CAS-treated patients and 1176 CEA-treated patients) were enrolled from 36 centres. The primary outcome was 4.3% (95% CI 3.2–5.6%) and 4.7% (95%CI 3.5–6.3%) in the symptomatic and asymptomatic patients, respectively. No significant difference in the primary outcome was found between CAS and CEA in both symptomatic (p = 0.338) and asymptomatic (p = 0.890) patients. High- versus low-volume centre significantly related to lower rate of primary outcome in CEA-treated patients (OR 2.54; 95%CI 1.19–5.44; p = 0.017) and asymptomatic patients (OR 2.54; 95%CI 1.42–4.54; p = 0.002). CEA and CAS decided by surgeons’ discretion have comparable risks among patients with carotid artery stenosis in China. Both CEA and CAS should be avoided in asymptomatic patients until a consistently low complication rate is showed with centre-level audits. Medical treatment for patients with carotid stenosis in China needs to be improved. Trial registration: NCT01994187 ( ClinicalTrials.gov ).

Stroke has been considered as one of the underlying diseases that increases the probability of severe infection and mortality. Meanwhile, there are ongoing reports of stroke subsequent to COVID-19 infection. In this narrative paper, we reviewed major neurologic adverse drug reactions (ADRs) and pharmacokinetics of drugs which are routinely used for COVID-19 infection and their potential drug–drug interactions (PDDIs) with common drugs used for the treatment of stroke. It is highly recommended to monitor patients on chloroquine (CQ), hydroxychloroquine (HCQ), antiviral drugs, and/or corticosteroids about initiation or progression of cardiac arrhythmias, delirium, seizure, myopathy, and/or neuropathy. In addition, PDDIs of anti-COVID-19 drugs with tissue plasminogen activator (tPA), anticoagulants, antiaggregants, statins, antihypertensive agents, and iodine-contrast agents should be considered. The most dangerous PDDIs were interaction of lopinavir/ritonavir or atazanavir with clopidogrel, prasugrel, and new oral anticoagulants (NOACs).

Background and purpose Drug-eluting balloons (DEBs) have been proposed as an option for the treatment of in-stent restenosis (ISR) following carotid artery stent placement. We report our experience and review of literature to provide additional data. Methods For literature review, PubMed search was conducted to identify studies published between 2005 and 2019, reporting data on management of carotid ISR with DEBs. Two cases with carotid ISR, which were successfully treated with DEB at our facility, were also included in the final compilation of results RESULTS: A total of seven studies demonstrating the use of the DEBs for treatment of carotid ISR were identified. They encompassed 31 patients, 11 (35.5%) of whom presented with symptomatic ISR, with the remaining 20 patients (64.5%) asymptomatic. DEB angioplasty followed by stent placement was performed in 3 patients, whereas DEB alone was utilized in 28 patients. Periprocedural complications included asymptomatic dissection from DEB inflation in 1 patient and transient neurological deficits in another patient. Follow-up period was variable and ranged from 1 month to 5 years. Three patients were noted to develop recurrent asymptomatic stenosis, whereas 1 patient developed an episode of symptomatic restenosis post procedural on follow-up. In our two cases, both patients were noted to have protracted period of hypotension postprocedure without any new or recurrent neurological symptoms. Conclusion The use of DEBs is a promising development and a viable alternative for management of severe and recurrent carotid ISR.

Background: Neurological deterioration (ND) has a major influence on the prognosis of intracerebral hemorrhage (ICH); however, factors associated with ND occurring after 24 h of ICH onset are unknown. Methods: We performed exploratory analyses of data from the Antihypertensive Treatment of Acute Cerebral Hemorrhage 2 trial, which compared intensive and standard blood pressure lowering treatment in ICH. NDs were captured on the adverse event case report form. Logistic regression analysis was performed to examine the independent predictors of late ND. Results: Among 1,000 participants with acute ICH, 82 patients (8.2%) developed early ND (≤24 h), and 64 (6.4%) had late ND. Baseline hematoma volume (adjusted OR [aOR] per 1-cm3 increase 1.04, 95% CI 1.02–1.06, p < 0.0001), hematoma volume increase in 24 h (aOR 2.24, 95% CI 1.23–4.07, p = 0.008), and the presence of intraventricular hemorrhage (IVH; aOR 2.38, 95% CI 1.32–4.29, p = 0.004) were independent predictors of late ND (vs. no late ND). Late ND was a significant risk factor for poor 90-day outcome (OR 3.46, 95% CI 1.82–6.56). No statistically significant difference in the incidence of late ND was noted between the 2 treatment groups. Conclusions: Initial hematoma volume, early hematoma volume expansion, and IVH are independent predictors of late ND after ICH. Intensive reduction in the systolic blood pressure level does not prevent the development of late ND.

The spot sign is associated with intracerebral hemorrhage (ICH) expansion and neurological decline. However, the relationship of the spot sign to secondary intraventricular hemorrhage (IVH) has not been well established. The presence of the spot sign in secondary IVH may provide information regarding neurologic outcome in a population with known poor prognosis. A subset analysis was performed of patients with IVH from the Antihypertensive Treatment of Acute Cerebral Hemorrhage 2 (ATACH-II) study, a randomized clinical trial examining the effect of intensive blood pressure reduction on hematoma expansion. The presence of the spot sign was determined on CTA and IVH expansion was measured in the first 24 hours. The primary outcome measure was early neurological decline (END), defined as ≥ 2-point decrease in Glasgow Coma Scale (GCS) score or ≥ 4-point increase in NIH Stroke Scale (NIHSS). Secondary outcomes including various radiological and clinical factors were also measured. Of 57 patients included in this analysis, the spot sign was present in 17 (29.8%). The spot sign was a predictor of END in univariate (P

Nail-patella syndrome (NPS) is a rare disorder characterized by abnormal development of ectodermal and mesodermal tissues. Classically, NPS presents as a triad of nail dysplasia, dysplastic patellae, and bony exostoses of the ilia known as “iliac horns.” Apart from dermatological and skeletal abnormalities, patients may also have involvement of ophthalmologic and renal systems. The underlying molecular etiology in NPS is the mutation of LMX1B homeobox gene which results in loss of function of its protein also called LMX1B, a DNA-binding protein belonging to the larger LIM-homeodomain transcription factor family. Normal LMX1B gene and protein function are essential for dorsalization of the vertebrate limb bud, development of anterior eye structures, skull formation, and differentiation and migration of neurons in the central nervous system. We report a case of confirmed NPS presenting with congenital aplasia of the internal carotid artery and believe this is the first report of cerebrovascular developmental abnormality associated with NPS.

Supplemental Digital Content is available in the text., Background: To determine the exposure risk for coronavirus 2019 (COVID-19) during neurology practice. Neurological manifestations of COVID-19 are increasingly being recognized mandating high level of participation by neurologists. Methods: An American Academy of Neurology survey inquiring about various aspects of COVID-19 exposure was sent to a random sample of 800 active American Academy of Neurology members who work in the United States. Use of second tier protection (1 or more including sterile gloves, surgical gown, protective goggles/face shield but not N95 mask) or maximum protection (N95 mask in addition to second tier protection) during clinical encounter with suspected/confirmed COVID-19 patients was inquired. Results: Of the 81 respondents, 38% indicated exposure to COVID-19 at work, 1% at home, and none outside of work/home. Of the 28 respondents who did experience at least 1 symptom of COVID-19, tiredness (32%) or diarrhea (8%) were reported. One respondent tested positive out of 12 (17%) of respondents who were tested for COVID-19 within the last 2 weeks. One respondent received health care at an emergency department/urgent care or was hospitalized related to COVID-19. When seeing patients, maximum protection personal protective equipment was used either always or most of the times by 16% of respondents in outpatient setting and 56% of respondents in inpatient settings, respectively. Conclusions: The data could enhance our knowledge of the factors that contribute to COVID-19 exposure during neurology practice in United States, and inform education and advocacy efforts to neurology providers, trainees, and patients in this unprecedented pandemic.

INTRODUCTION There are a number of small case series examining new robotic surgical systems, but this is the first large case series assessing the feasibility of the Versius® system from CMR Surgical (1 Evolution Business Park, Cambridge, UK) in a multi-specialty setting. MATERIALS AND METHODS All patients undergoing Versius®-assisted surgery in a previously robot-naive centre were consented for collection of data on demographics, pre-, intra-, and postoperative outcomes. Data collection was performed prospectively from the start of the robotic surgical programme. RESULTS 160 operations were performed over a 19-month period, including 68 colorectal, 60 gynaecology, and 32 general surgery cases. The conversion rate to open surgery was 4.4% for colorectal, and 0% for gynaecology and general surgery. Median length of stay was 6 days for colorectal, 1 day for gynaecology, and 0 days for general surgery. Other outcomes were comparable to existing literature for robotic assisted surgery. CONCLUSION The Versius® system is safe and feasible for use in a multi-specialty minimally invasive surgery programme, including colorectal, general surgical & gynaecological cases, and operative volume can be safely and easily scaled up in a district general hospital setting without prior robotic surgical experience.

Objectives Acute ischemic stroke patients with severe acute respiratory syndrome coronavirus maybe candidates for acute revascularization treatments (intravenous thrombolysis and/or mechanical thrombectomy). Materials and Methods We analyzed the data from 62 healthcare facilities to determine the odds of receiving acute revascularization treatments in severe acute respiratory syndrome coronavirus infected patients and determined the odds of composite of death and non-routine discharge with severe acute respiratory syndrome coronavirus infected and non-infected patients undergoing acute revascularization treatments after adjusting for potential confounders. Results Acute ischemic stroke patients with severe acute respiratory syndrome coronavirus infection were significantly less likely to receive acute revascularization treatments (odds ratio 0.6, 95% confidence interval 0.5–0.8, p = 0.0001). Among ischemic stroke patients who received acute revascularization treatments, severe acute respiratory syndrome coronavirus infection was associated with increased odds of death or non-routine discharge (odds ratio 3.0, 95% confidence interval 1.8–5.1). The higher odds death or non-routine discharge (odds ratio 2.1, 95% confidence interval 1.9–2.3) with severe acute respiratory syndrome coronavirus infection were observed in all ischemic stroke patients without any modifying effect of acute revascularization treatments (interaction term for death (p = 0.9) or death or non-routine discharge (p = 0.2). Conclusions Patients with acute ischemic stroke with severe acute respiratory syndrome coronavirus infection were significantly less likely to receive acute revascularization treatments. Severe acute respiratory syndrome coronavirus infection was associated with a significantly higher rate of death or non-routine discharge among acute ischemic stroke patients receiving revascularization treatments.

Background Among prognostic imaging variables, the hematoma volume on admission computed tomography (CT) has long been considered the strongest predictor of outcome and mortality in intracerebral hemorrhage. Aims To examine whether different features of hematoma shape are associated with functional outcome in deep intracerebral hemorrhage. Methods We analyzed 790 patients from the ATACH-2 trial, and 14 shape features were quantified. We calculated Spearman’s Rho to assess the correlation between shape features and three-month modified Rankin scale (mRS) score, and the area under the receiver operating characteristic curve (AUC) to quantify the association between shape features and poor outcome defined as mRS>2 as well as mRS > 3. Results Among 14 shape features, the maximum intracerebral hemorrhage diameter in the coronal plane was the strongest predictor of functional outcome, with a maximum coronal diameter >∼3.5 cm indicating higher three-month mRS scores. The maximum coronal diameter versus hematoma volume yielded a Rho of 0.40 versus 0.35 ( p = 0.006), an AUC[mRS>2] of 0.71 versus 0.68 ( p = 0.004), and an AUC[mRS>3] of 0.71 versus 0.69 ( p = 0.029). In multiple regression analysis adjusted for known outcome predictors, the maximum coronal diameter was independently associated with three-month mRS (p Conclusions A coronal-plane maximum diameter measurement offers greater prognostic value in deep intracerebral hemorrhage than hematoma volume. This simple shape metric may expedite assessment of admission head CTs, offer a potential biomarker for hematoma size eligibility criteria in clinical trials, and may substitute volume in prognostic intracerebral hemorrhage scoring systems.

Background To explore how the clinical impact of heart rate (HR) and heart rate variabilities (HRV) during the initial 24 hours after acute intracerebral hemorrhage (ICH) contribute to worse clinical outcomes. Methods and Results In the ATACH‐2 (Antihypertensive Treatment in Intracerebral Hemorrhage 2) trial, the HR was recorded for every 15 minutes from baseline to 1 hour and hourly during the initial 24 hours post‐randomization. We calculated the following: mean, standard deviation, coefficient of variation, successive variation, and average real variability (ARV). Outcomes were hematoma expansion at 24 hours and unfavorable functional outcome, defined as modified Rankin Scale score 4 to 6 at 90 days. Of the 1000 subjects in ATACH‐2, 994 with available HR data were included in the analyses. Overall, 262 experienced hematoma expansion, and 362 had unfavorable outcomes. Increased mean HR was linearly associated with unfavorable outcome (per 10 bpm increase adjusted odds ratio [aOR], 1.31, 95% CI, 1.14–1.50) but not with hematoma expansion, while HR‐ARV was associated with hematoma expansion (aOR, 1.06, 95% CI, 1.01–1.12) and unfavorable outcome (aOR, 1.07, 95% CI, 1.01–1.3). Every 10‐bpm increase in mean HR increased the probability of unfavorable outcome by 4.3%, while every 1 increase in HR‐ARV increased the probability of hematoma expansion by 1.1% and unfavorable outcome by 1.3%. Conclusions Increased mean HR and HR‐ARV within the initial 24 hours were independently associated with unfavorable outcome in acute ICH. Moreover, HR‐ARV was associated with hematoma expansion at 24 hours. This may have future therapeutic implications to accommodate HR and HRV in acute ICH. Registration URL: https://www.clinicaltrials.gov ; Unique Identifier: NCT01176565.

To identify rates of and factors associated with repeat revascularization in a large cohort of patients prospectively followed over 10 years in Carotid Revascularization Endarterectomy versus Stenting Trial.We compared the effect of carotid angioplasty and stenting (CAS) versus carotid endarterectomy (CEA) on risk of repeat revascularization after adjusting for age, sex, symptomatic status, and initial severity of stenosis (≥70% vs.70%) using Cox proportional hazards analysis. We used Kaplan-Meier analysis to assess repeat revascularization-free survival for the overall cohort.Repeat revascularization was performed in 90 (3.9%, 95% confidence interval [CI] 3.1%-4.8%) of 2318 patients; 6 (6.7%, 95% CI 2.5%-14.0%) patients experienced the composite end point of any stroke, myocardial infarction, or death within 30 days after repeat revascularization. There was no difference in risk of repeat revascularization in patients who underwent CAS (compared with CEA) as the index procedure (hazard ratio 0.92, 95% CI 0.69-1.23, P = 0.5765). Patient's age (hazard ratio 1.01, 95% CI 1.01-1.02, P0.0001) was associated with performance of repeat revascularization. Mean ± SD repeat revascularization-free survival was 8.2 ± 0.1 years and 8.0 ± 0.1 years for CAS and CEA, respectively (log-rank test P = 0.0823).A low rate of repeat revascularization was seen without any significant difference among patients who underwent CEA or CAS over 10 years. The 6.7% rate of composite end point within 30 days after procedure highlights the need for standardizing the indications for repeat revascularization.

Background and purpose Cerebral vasodilatory capacity assessment for risk stratification in patients with extracranial arterial stenosis or occlusion may be useful. We describe a new method that assesses cerebral vasodilatory capacity as part of catheter-based cerebral angiography. Methods We prospectively assessed regional cerebral blood volume (rCBV) in the arterial distribution of interest using a controlled contrast injection in the common carotid or the subclavian arteries. rCBV maps were created using a predefined algorithm based on contrast distribution in the venous phase (voxel size: .466 mm3 ). rCBV maps were acquired again after selective administration of intra-arterial nicardipine (2.0 mg) distal to the stenosis. Two independent observers graded the change in rCBV in 10 predefined anatomical regions within the tributaries of the artery of interest (0 = reduction, 1 = no change, 2 = increase) and total rCBV change scores were summated. Results Twenty-five patients with internal carotid artery stenosis (n = 18; 0-90% in severity) or extracranial vertebral artery stenosis (n = 7; 0-100% in severity) were assessed. There was an increase in rCBV in a tributary of the artery of interest in 18 of 25 after intra-arterial nicardipine (mean score: 11.98; range 0-19.5). There was no change or decrease in rCBV in 7 of 25 patients. The mean rCBV change score was similar in patients with an assessment of internal carotid artery or vertebral artery distributions (12.2 ± 5.3; 11.4 ± 2.5; P = .68). Conclusion Selective vasodilatory response to intra-arterial nicardipine in the affected arterial distribution during catheter-based cerebral angiography may provide new data for risk stratification.

BackgroundProcedural time in patients with acute ischemic stroke (AIS) undergoing mechanical thrombectomy may affect clinical outcomes. We performed a pooled analysis of the effect of procedural time on clinical outcomes using data from three prospective endovascular treatment trials.ObjectiveTo examine the relationship between endovascular procedural time and clinical outcomes of patients with AIS following endovascular treatment.MethodsWe analyzed data from SWIFT, STAR, and SWIFT PRIME studies, including baseline characteristics: National Institutes of Health Stroke Scale (NIHSS) score on admission, intracranial hemorrhage rates, and modified Rankin Scale score at 3 months. The Thrombolysis in Cerebral Infarction (TICI) scale was used to grade postprocedure recanalization. We recorded two procedural time intervals: (1) symptom onset to groin puncture and (2) groin puncture to angiographic recanalization. A multivariate analysis was performed using a logistic regression model to analyze predictors of unfavorable outcome.ResultsWe analyzed 301 patients who had undergone endovascular treatment and had near-complete or complete recanalization (TICI 2b or 3). At 3 months, 122 patients (40.5%) had unfavorable outcomes. The rate of favorable outcomes was significantly higher when the procedural time was ConclusionProcedural time in patients with stroke undergoing mechanical thrombectomy may be an important determinant of favorable outcomes in those with recanalization.

OBJECTIVE To determine the association between clinical outcomes and acute systolic blood pressure (SBP) levels achieved after intracerebral hemorrhage (ICH). METHODS Eligible patients who were randomized to the ATACH-2 (Antihypertensive Treatment in Intracerebral Hemorrhage 2) trial (ClinicalTrials.gov: NCT01176565) were divided into 5 groups by 10-mmHg strata of average hourly minimum SBP (

Background: The natural history of vertebrobasilar artery (VBA) stenosis or occlusion remains understudied. Methods: Patients with diagnosis of ischemic stroke or transient ischemic attack (TIA) who were noted to have VBA stenosis based on computed tomography or magnetic resonance imaging or catheter-based angiogram were selected from Taiwan Stroke Registry. Cox proportional hazards model was used to determine the hazards ratio (HR) of recurrent stroke and death within 1 year of index event in various groups based on severity of VBA stenosis (none to mild: 0–49%; moderate to severe: 50–99%: occlusion: 100%) after adjusting for differences in demographic and clinical characteristics between groups at baseline evaluation. Results: None to mild or moderate to severe VBA stenosis was diagnosed in 6972 (66%) and 3,137 (29.8%) among 10,515 patients, respectively, and occlusion was identified in 406 (3.8%) patients. Comparing with patients who showed none to mild stenosis of VBA, there was a significantly higher risk of recurrent stroke (HR 1.21, 95% CI 1.01–1.45) among patients with moderate to severe VBA stenosis. There was a nonsignificantly higher risk of recurrent stroke (HR 1.49, 95% CI 0.99–2.22) and significantly higher risk of death (HR 2.21, 95% CI 1.72–2.83), among patients with VBA occlusion after adjustment of potential confounders. Conclusions: VBA stenosis or occlusion was relatively prevalent among patients with TIA or ischemic stroke and associated with higher risk of recurrent stroke and death in patients with ischemic stroke or TIA who had large artery atherosclerosis.

Supplemental Digital Content is available in the text., Background and Purpose: The frequency of ischemic stroke in patients with coronavirus disease 2019 (COVID-19) varies in the current literature, and risk factors are unknown. We assessed the incidence, risk factors, and outcomes of acute ischemic stroke in hospitalized patients with COVID-19. Methods: We included patients with a laboratory-confirmed SARS-CoV-2 (severe acute respiratory syndrome coronavirus-2) infection admitted in 16 Dutch hospitals participating in the international CAPACITY-COVID registry between March 1 and August 1, 2020. Patients were screened for the occurrence of acute ischemic stroke. We calculated the cumulative incidence of ischemic stroke and compared risk factors, cardiovascular complications, and in-hospital mortality in patients with and without ischemic stroke. Results: We included 2147 patients with COVID-19, of whom 586 (27.3%) needed treatment at an intensive care unit. Thirty-eight patients (1.8%) had an ischemic stroke. Patients with stroke were older but did not differ in sex or cardiovascular risk factors. Median time between the onset of COVID-19 symptoms and diagnosis of stroke was 2 weeks. The incidence of ischemic stroke was higher among patients who were treated at an intensive care unit (16/586; 2.7% versus nonintensive care unit, 22/1561; 1.4%; P=0.039). Pulmonary embolism was more common in patients with (8/38; 21.1%) than in those without stroke (160/2109; 7.6%; adjusted risk ratio, 2.08 [95% CI, 1.52–2.84]). Twenty-seven patients with ischemic stroke (71.1%) died during admission or were functionally dependent at discharge. Patients with ischemic stroke were at a higher risk of in-hospital mortality (adjusted risk ratio, 1.56 [95% CI, 1.13–2.15]) than patients without stroke. Conclusions: In this multicenter cohort study, the cumulative incidence of acute ischemic stroke in hospitalized patients with COVID-19 was ≈2%, with a higher risk in patients treated at an intensive care unit. The majority of stroke patients had a poor outcome. The association between ischemic stroke and pulmonary embolism warrants further investigation.

Background There is persistent uncertainty over the benefits of early intensive systolic blood pressure lowering in acute intracerebral hemorrhage. In particular, over the timing, target, and intensity of systolic blood pressure control for optimum balance of potential benefits (i.e. functional recovery) and risks (e.g. cerebral ischemia). Aims To determine associations of early systolic blood pressure lowering parameters and outcomes in patients with a hypertensive response in acute intracerebral hemorrhage. Secondary aims are to identify the modifying effects of patient characteristics and an optimal systolic blood pressure lowering profile. Methods Individual participant data pooled analyses of two large, multicenter, randomized controlled trials specifically undertaken to assess the effects of early intensive systolic blood pressure reduction on clinical outcomes in acute intracerebral hemorrhage: the Intensive Blood Pressure in Acute Intracerebral Hemorrhage Trial (INTERACT2) and the Antihypertensive Treatment of Acute Cerebral Hemorrhage (ATACH-II) trial. Combined data will include baseline characteristics; systolic blood pressure in the first 24 h; process of care measures; and key efficacy and safety outcomes. Outcomes The primary outcome is functional recovery, defined by an ordinal distribution of scores on the modified Rankin scale at 90 days post-randomization. Secondary outcomes include various standard binary cut-points for disability-free survival on the modified Rankin scale, and health-related quality of life at 90 days. Safety outcomes include symptomatic hypotension requiring corrective therapy and early neurologic deterioration within 24 h, and deaths, any serious adverse event, and cardiac and renal serious adverse events, within 90 days. Discussion A pre-determined protocol was developed to facilitate successful collaboration and reduce analysis bias arising from prior knowledge of the findings. Clinical trial registration URL: http://www.clinicaltrials.gov . Unique identifiers for INTERACT2 (NCT00716079) and ATACH-II (NCT01176565).

Background We performed this study to identify demographic, clinical, and angiographic characteristics of adult patients with angiographically confirmed vertebral artery occlusive disease (VAOD) and associated risk factors. Methods The demographic and clinical characteristics, and angiographic features were ascertained using predefined criteria. Controls were selected from the National Health and Nutrition Examination Surveys matched according to age, sex, and ethnicity. A stepwise logistic regression for odds ratio (OR) was performed to identify the effects of risk factors on occurrence of VAOD. Results Of 56 patients with VAOD (mean age ± standard deviation [SD]; 65.4 ± 11.7years, 44.6% women), 37.5% were classified as suffering from moderate stenosis (50%-69%), 16.1% from severe stenosis (70%-99%), and 46.4% from occlusion of at least 1 vertebral artery. There was a significantly higher severity of stenosis (percentage with SD; 88.1 ± 16.5 versus 75.4 ± 20.8, P = .02) and frequency of bilateral vertebral artery disease in patients with ischemic symptoms (40.9% versus 8.8%, P = .004). In the multivariate analysis, hypertension (OR 3.0; 95% confidence interval [CI], 1.4-6.5), diabetes mellitus (OR 2.5; 95% CI, 1.4-4.6), coronary artery disease (OR 3.2; 95% CI, 1.7-6.0), and active cigarette smoking (OR 3.1; 95% CI, 1.5-6.3) were significantly associated with vertebral artery disease. Conclusions Severity of stenosis and bilateral involvement were associated with symptomatic VAOD. Hypertension, diabetes mellitus, coronary artery disease, and active cigarette smoking were associated with occurrence of VAOD.

The ASA/AHA guidelines recommend a fixed dose of 90 mg of intravenous (IV) recombinant tissue plasminogen activator (rt-PA) for acute stroke patients weighing more than 100 kg. We aimed to determine if body weight100 kg (and receiving0.9 mg/kg dose) independently influence patient clinical outcomes following IV rt-PA treatment.We pooled data from IV rt-PA treatment arms from 3 randomized controlled clinical trials; NINDS IV rt-PA study, Interventional Management of Stroke 3 and ALIAS (part 1 and 2). Baseline characteristic, hospital course and 90-day mRS were compared between patients100 kg and those ≤100 kg body weight. Multivariate logistic regression model was used to identify the independent effect of100 kg body weight on favorable 90-day outcome (defined as mRS 0-2), the rate of symptomatic intracranial hemorrhage, and poor 90-day outcome (mRS 4-6).Among 873 patients treated with IV rt-PA, a total of 105 (12%) subjects had body weight100 kg. Compared with patients having ≤100 kg body weight, the rate of favorable outcome at 90 days was not significantly different among patients with100 kg body weight (OR: 0.99; 95% CI: 0.91-1.01; p=0.91) , after adjusting for potential confounders. The ordinal analysis did not show any significant shift in the distribution of 90-day mRS score in patients with100 kg body weight (OR, 0.93; 95% CI, 0.64-1.37; P = 0.74) CONCLUSIONS: There was no reduction in the rate of favorable outcome in patients with acute ischemic stroke with body weight100 kg who received0.9 mg/kg dose of IV rt-PA. Our results support the current recommendations in the ASA/AHA guidelines.

Background: Myasthenia gravis (MG) is an auto-immune disease, and the mainstay of therapy is immunomodulation. Such patients are at high risk of acquiring any infections. Hence, we sought to determine the impact of the current global pandemic COVID-19 infection in MG patients.Methods: For our study, we used Cerner Real-World DataTM that was provided through Cerner’s HealtheDataLab research tool. We ran a database query from January 2019 to July 2020 in our study. To extract these patients’ data, we used ICD 9-CM, ICD-10, and SNOMED-CT codes. We report data using means, range, and prevalence rates. The p-values were calculated using the two-sample t-test and Pearson’s chi-squared test. Results:In the COVID-19 data set, a total of twenty-seven myasthenia patients were identified with a positive COVID-19 infection, and four diagnosed with an exacerbation. Male to female ratio was equal and one unknown gender (3.7%) with a mean (± SD) age of 64.33 ± 18.42 years. This study group was compared with a non-COVID-19 data set in which a total of sixty-four myasthenia patients were identified, and twenty-three had an exacerbation. Among the hospitalized patients in the two groups, the mean length of hospitalization for all the myasthenia patients in the COVID-19 data set was 8.28 days (n=7), and the non-COVID-19 set was 4.33 days (n=6), and it was statistically significant (p-value= 0.007). Conclusion: The mean length of hospital stay is prolonged in Myasthenia patients who tested positive for COVID-19.

Background and Purpose: Acute ischemic stroke may occur in patients with Coronavirus disease 2019 but risk factors, in hospital events, and outcomes are not well studied in large cohorts. We identified risk factors, co-morbidities, and outcomes in patients with Coronavirus disease 2019 with or without acute ischemic stroke and compared with patients without Coronavirus disease 2019 and acute ischemic stroke. Methods: We analyzed the data from 54 healthcare facilities using the Cerner de-identified Coronavirus disease 2019 dataset. The dataset included patients with an emergency department or inpatient encounter with a discharge diagnoses codes that could be associated to suspicion of or exposure to Coronavirus disease 2019, or confirmed Coronavirus disease 2019. Results: A total of 103 (1.3%) patients developed acute ischemic stroke among 8,163 patients with Coronavirus disease 2019. Among all Coronavirus disease 2019 patients, the proportion of patients with hypertension, diabetes mellitus, hyperlipidemia, atrial fibrillation and congestive heart failure was significantly higher among those with acute ischemic stroke. Acute ischemic stroke was associated with discharge to destination other than home or death (relative risk 2.1, 95% confidence interval 1.7-2.4, p Conclusions: Acute ischemic stroke was infrequent in patients with Coronavirus disease 2019 and usually occurs in presence of other cardiovascular risk factors. The risk of discharge to destination other than home or death increased two folds with occurrence of acute ischemic stroke in patients with Coronavirus disease 2019.

Background and purpose: To determine if computed tomography (CT) perfusion (CTP) abnormalities in patients with transient ischemic attacks (TIA) are associated with development of ischemic strokes or adverse cardiovascular events within 24 months. Methods: Patients with a diagnosis of TIA who underwent CTP within 24 hours of symptom onset as part of the stroke/TIA imaging protocol were analysed. Abnormality was defined as an area of well demarcated mean transit time delay and/or cerebral blood flow reduction corresponding to an arterial territory as identified by an independent neuroradiologist. The patients were followed for at least 3 months and up to 24 months to identify occurrence of ischemic stroke and cardiovascular events (myocardial infarction or ischemia). Results: A total of 78 patients (mean age 67.60 +/- 15.1 ; 48 were men) with a diagnosis of TIA. A total of 17 patients (22%) had documented CTP abnormalities. Patients with CTP abnormalities were older and more likely to be men. There was no difference in the rates of ischemic stroke (5.9 % vs 3.3 %), or cardiovascular events (0% versus 1.6 %) when patients with CTP abnormalities were compared to those with normal CTP. Conclusions: In patients with TIA, an abnormal CTP does not predict the occurence of new ischemic stroke or cardiovascular events during follow up.

Background: Histamine (H) 2 blockers led to a significant increase of the relative bioavailability of nimodipine and therefore may change tolerability of nimodipine in patients with aneurysmal subarachnoid hemorrhage (SAH). Objective: To determine the effect of H2 blockers on outcome of SAH patients being treated with nimodipine on outcomes. Methods: We analyzed data from Cerner Health Facts® which collected data from participating facilities from January 1st, 2000 to July 1st, 2018. We identified SAH patients who underwent endovascular or surgical treatment for intracranial aneurysm and received nimodipine with or without H2 blockers. Outcome was defined by discharge destination and classified into none to minimal disability, moderate to severe disability, or death. Results: A total of 815 (54.8%) of 1488 SAH patients received H2 blockers in addition to nimodipine. There were no differences in rates of cerebral ischemia (8.8% versus 9.8%) or performance of angioplasty (3.8% versus 3.7%) between patients who did or did not receive H2 blockers. There were no differences in rates of intubation/mechanical ventilation (26.0% versus 29.3%) or intra-procedural cerebral infarction (3.4% versus 2.8%) between the two groups. There was no difference in in hospital mortality rates (10.9% versus 10.2%) or none to minimal disability (41.8% versus 38.2%) between patients who did or did not receive H2 blockers. Conclusions: H2 blockers are frequently used with nimodipine in SAH patients and did not appear to adversely affect rates of death or disability. The finding does not support any clinically significant interaction between H2 blockers and nimodipine in SAH patients.

Background: To identify the beneficial effects of thrombectomy capable hospitals (TCHs), we compared the rates of in-hospital adverse events and discharge outcomes among ischemic stroke patients admitted to thrombectomy capable and non-thrombectomy capable hospitals in the United States. Methods: We obtained the data from the Nationwide Inpatient Sample from 2012 and 2017. Thrombectomy capable hospitals were identified based on number of thrombectomy procedures performed by hospital per year among ischemic stroke patients. If an hospital performed ten or more thrombectomy procedures, it was labelled as thrombecotomy capable hospital. The analysis was limited to patients (age ≥18 years) discharged with a principal diagnosis of ischemic stroke (International Classification of Disease 433.x1-434.x1 (ICD-9) or I63 (ICD-10). The impact of TCHs admissions on in-hospital outcomes was assessed in a comparative analysis of propensity-matched groups of patients. Results: We identified a total of 2,826,335 patients with primary ischemic stroke patients. After adjusting for age, gender, race or ethnicity, comorbidities, All Patients Refined Diagnosis Related Groups (APR-DRG)-based disease severity, and hospital teaching status, patients admitted to TCHs were at lower risk of in-hospital adverse events complications: pneumonia (odds ratio [OR], 0.86; 95% confidence interval [CI], 0.80-0.93), urinary tract infection (OR, 0.87; 95% CI, 0.84-0.91)and sepsis (OR, 0.92; 95% CI, 0.84-1.00). Patients admitted to TCH were more likely to receive thrombolysis (OR, 1.29; 95% CI, 1.30-1.36). The mean cost of hospitalization of the patients was significantly higher in patients admitted at TCHs compared with those admitted at non-thrombectomy capable $74765 vs $60530, P < .0001). The patients admitted to TCHs had lower inpatient mortality (OR, 0.82; 95% CI, 0.78-.88) and were more likely to be discharged with none to minimal disability (OR, 1.09; 95% CI, 1.06-1.12). Conclusions: Compared with non-thrombectomy capable admissions, patients admitted to TCHs are less likely to experience hospital adverse events and more likely to experience better discharge outcomes.

Background and Purpose: In present-day intracerebral hemorrhage (ICH) trials, hematoma expansion (HE) is often analyzed as a binary variable - present or absent. However, dichotomizing intrinsically wide-ranging variables discards substantial information reflective of treatment effect and can reduce the ability to detect relationships between the exposure and outcome of interest. We explored the concept of a “HE shift analysis” as a novel analytic mode for ICH treatment trials using previously published clinical trial data. Methods: Using data from the Antihypertensive Treatment of Acute Cerebral Hemorrhage II (ATACH-2) trial, patients were stratified by treatment status (intensive vs. standard blood pressure lowering with IV nicardipine) and HE shift was evaluated by generating strata based on a) previously established HE definitions, b) quartiles of 24-hour total hematoma volume, and c) quartiles of 24-hour total hematoma volume (THV) change. The relationship between blood pressure treatment and hematoma expansion shift was explored using proportional odds models and adjusted Wilcoxon testing. Results: The primary analysis population included 863 patients. In both treatment groups, approximately one-third of patients exhibited no hematoma growth. Using a conventional threshold, significant intraparenchymal expansion (≥33%) was reduced by 5.8% in those assigned to the intensive therapy arm (aOR: 0.77 [95% CI: 0.60-0.99], Figure 1A). The stratified quartiles of 24-hour total hematoma volumes were associated with a 5% shift within the highest and lowest strata in the intensive arm, (aOR: 0.83 [0.66-1.05], Figure 1B). Intensive therapy was associated with a 5.2% reduction from > 3 mL to 0.5-3 mL (aOR: 0.86 [0.68-1.09], Figure 1C). Conclusions: A shift analysis model of HE provides additional insights into the biological effects of a given therapy and may be an alternate way to assess hemostatic agents in future hemorrhage trials.

Context: Over the past few decades, transradial access has been increasingly utilized for neurointerventional procedures including carotid angioplasty and stent placement (CAS). Objective: To compare the outcomes of CAS performed via transradial approach with those performed using transfemoral approach within the same institution. Methods: We analyzed all the elective CAS procedures performed at our institute in the last 48 months and divided the procedures based on initial approach (transradial or transfemoral). Both approaches were used by same interventionalists to minimize inter-operator variability. We compared the rates of technical failure; hemorrhagic complications classified as major (hemoglobin decrease >5 g/dL or intracranial hemorrhage with deficits), minor (hemoglobin decreases 3-5 g/dL or intracranial hemorrhage without residual deficits), or insignificant; and any stroke and/or death within 1-month post procedure. Results: A total of 120 elective CAS procedures were performed at our institution; 84 patients (70%) were initiated as transfemoral and 36 patients (30%) were initiated as transradial approach. There were 6 (16%) CAS procedures initiated as trans-radial but later switched to transfemoral due to anatomical and/or technical difficulties. Similarly, 1(1.2%) procedure was switched to transradial from transfemoral. So finally, 89 (74%) patients had transfemoral approach and 31 (26%) patients had transradial approach to CAS. The median age was similar between the two groups (66.5 years versus 67.3 years).The rates of major hemorrhagic complications were 2 (2.2 %) and 0 (0%) in CAS performed using tranfemoral and tranradial approaches, respectively. The rate of any stroke and/or death within 30 days post procedure was 5 (5.6 %) and 1 (3.2 %) in CAS performed using transfemoral and transradial approaches, respectively.The median fluoroscopy time was 36.1 minutes and 34.4 minutes using transfemoral and transfemoral approaches, respectively (p =0.72). Conclusions: Transradial approach is comparable to transfemoral approach for performance of CAS in regard to clinical endpoints although the rates of technical failure remain relatively high in patients in whom CAS was initiated from transradial approach.

Background: Intra-arterial or intravenous platelet glycoprotein (GP) IIb/IIIa inhibitors have been used as adjunct to stent placement of carotid stenosis in patients with ischemic stroke or transient ischemic attack. Objective: To determine the proportion of patients with ischemic stroke or transient ischemic attack who received platelet GP IIb/IIIa inhibitors as adjunct to carotid stent placement and associated outcomes. Methods: We analyzed data from Cerner Health Facts® which collected data from participating facilities from January 1, 2000 to July 1, 2018. We identified patients with ischemic stroke or transient ischemic attack who underwent carotid stent placement for carotid stenosis and received Abciximab, Eptifibatide, or Tirofiban. Outcome was defined by discharge destination and classified into none to minimal disability, moderate to severe disability, or death. Results: A total of 8.4 % of 4567 patients with ischemic stroke or transient ischemic attack who underwent carotid stent placement for carotid stenosis received platelet GP IIb/IIIa inhibitors. Patients who received platelet GP IIb/IIIa inhibitors were more likely to experience cerebral ischemia (14.8% versus 7.5%) and undergo intubation/mechanical ventilation (4.4% versus 2%). There was a significant difference between patients who did or did not receive platelet GP IIb/IIIa inhibitors in terms of in hospital mortality rates (2.7% versus 1.2%, p=0.0152), none to mild disability (67.3% vs 75.7%, p=0.0003), and moderate to severe disability (30.1% vs 23.1%,p=0.0024). Conclusions: Adjunct use of platelet GP IIb/IIIa inhibitors in patients undergoing carotid stent placement for symptomatic carotid stenosis was associated with increased rates of in hospital mortality and moderate to severe disability.

Background: Recent trials have demonstrated a reduction in death or disability with endovascular treatment in patients with acute ischemic strokes. However, readmission rates and predictors are not known. Objective: To identify rates and factors associated with 30-day readmission after endovascular treatment in ischemic stroke patients. Methods: Nationwide Readmissions Data (NRD) between 2010 and 2017 was utilized to identify endovascular treatment in acute ischemic stroke patients using ICD-9 and ICD-10 codes. We used hierarchical logistic regression model to identify factors associated with 30-day readmissions. Results: Among 17, 562 acute ischemic stroke patients who survived to discharge after endovascular treatment, 2334 (13.29%) were readmitted within 30-days. Age => 65 years (odds ratio [OR]: 1.23, 95% confidence interval [CI]: 1.09 to 1.39, p =0.0005), chronic kidney disease (OR: 1.28, 95%CI: 1.12 to 1.47, p = 0.0004), congestive heart failure (OR: 1.25, 95%CI: 1.13 to 1.39, p Conclusion: In this large nationally representative study, nearly one in 10 patients were readmitted within 30 days after discharge in acute ischemic stroke patients undergoing endovascular treatment. Medical comorbidities and post procedure intracranial hemorrhage were associated with 30-day readmission.

Introduction: Endovascular treatment (EVT) is a widely proven method to treat patients diagnosed with intracranial large vessel occlusion. In order to ensure patients safety prior to and during EVT, preprocedural intubation has been adopted in many centers as a means for airway protection and immobilization. However, the correlation between site of vessel occlusion, need for intubation, and outcomes, has not yet been established. Methods: Through the utilization of a prospectively collected database at a comprehensive stroke center between 2012-2020, demographics, co-morbid conditions, intracerebral hemorrhage, mortality rate, and functional independence outcomes were examined. The outcomes and sites of occlusion between patients receiving mechanical thrombectomy (MT) treated while intubated versus those treated under conscious sedation (CS) were compared. Results: Out of 625 patients treated with MT, a total of 218 (34.9%) were treated while intubated (average age 70.3 ± 13.7, 37.2% women), and 407 (65.1%) were treated while under CS (average age 70.3 ± 13.7, 47.7% women); see Table 1 for baseline characteristics and outcomes. A higher number of patients requiring intubation had an occlusion in the basilar versus those only requiring CS. No differences were noted in regard to the proportion of patients receiving intubation or CS when treated for RMCA, LMCA, or internal carotid artery occlusions. Conclusion: Intubation + MT was associated with significantly worsened outcomes in regard to recanalization rates, functional outcome, and mortality. In anterior circulation strokes, intubation in RMCA patients were found to have poorer clinical outcome. Higher rates of intubation were also found to be needed in patients with basilar occlusions. Further research is required to determine whether site of occlusion dictates the need for intubation, and whether intubation allows for favorable outcome between R and LMCA occlusions.

Background: Hematoma expansion (HE) is an important therapeutic target in intracerebral hemorrhage. Recently proposed HE definitions have not been validated, and no previous definition has accounted for withdrawal of care (WOC). Objective: To compare conventional and revised definitions of hematoma expansion (HE), while accounting for WOC. Methods: We analyzed data from the ATACH-2 trial, comparing revised definitions of HE incorporating intraventricular hemorrhage (IVH) expansion to the conventional definition of “≥6 mL or ≥33%”. The primary outcome was modified Rankin Scale of 4-6 at 90-days. We calculated the incidence, sensitivity, specificity, positive and negative predictive values, and c- statistic for all definitions of HE. Definitions were compared using non-parametric methods. Secondary analyses were performed after removing patients who experienced WOC. Results: Primary analysis included 948 patients. Using the conventional definition, the sensitivity was 37.1% and specificity was 83.2% for the primary outcome. Sensitivity improved with all three revised definitions (53.3%, 48.7%, and 45.3%, respectively), with minimal change to specificity (78.4%, 80.5%, and 81.0%, respectively). The greatest improvement was seen with the definition “≥6 mL or ≥33% or any IVH”, with increased c -statistic from 60.2% to 65.9% (p < 0.001). Secondary analysis excluded 46 participants who experienced WOC. The revised definitions outperformed the conventional definition in this population as well, with the greatest improvement in c -statistic using “≥6 mL or ≥33% or any IVH” (58.1% vs 64.1%, p < 0.001). Conclusions: HE definitions incorporating intraventricular expansion outperformed conventional definitions for predicting poor outcome, even after accounting for care limitations.

Background: Revascularization of subacute or chronic internal carotid artery occlusion is technically feasible in some patients but carotid revascularization procedure needs to be optimized to improve the clinical success of the procedure. Objective: To describe our experience using intravascular ultrasound (IVUS) as adjunct to carotid revascularization procedure in patients with subacute or chronic internal carotid artery occlusion. Materials and Methods: Endovascular recanalization was attempted in 7 patients with symptomatic internal carotid artery occlusions between 3 and 11 days of symptoms onset. Distal protection device was deployed in all the patients followed by advancement of IVUS catheter (Eagle Eye Gold, 20 MHZ Digital, s5 Imaging System, Volcano Corp.) to obtain gray-scale and virtual histology (VH) images at regions of interest. IVUS images used to categorize occlusion content as: dark green- fibrous; yellow/green- fibrofatty; white- calcified; red- necrotic lipid core plaque on images. Intravascular thrombus was diagnosed an echolucent, homogeneous, well-delineated, diaphragm-like intraluminal structure. Results: The occlusion was recanalized successfully in all of 7 patients with median age 67.4±7.5 years. IVUS demonstrated intravascular thrombus in 5 of 7 patients. Fibrous and fibrofatty constituents of plaque were seen in 5 of the 7 patients in whom VH was done. Calcification and lipid necrotic core each were seen in 3 of 5 patients.5 patients with large thrombus burden on IVUS were treated using aspiration thrombectomy. Six of seven patients underwent stent placement and one patient underwent primary angioplasty. 5 of 7 patients had modified Rankin Scale of 0-2 at follow up (3 weeks to 4 months post procedure). Conclusions: IVUS provided valuable information to optimize carotid revascularization procedure in patients with subacute or chronic internal carotid artery occlusion.