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Spinal vascular malformations are rare, with dural arteriovenous fistulas (AVFs) accounting for the majority of the pathology. Unlike spinal arteriovenous malformations, which cause abrupt neurological change as a result of hemorrhage, spinal dural AVFs tend to result in a progressive myelopathy through venous congestion and cord edema. If diagnosed and treated early with endovascular embolization or microsurgery, some deficits may be reversible.

The diagnosis of a stroke mimic is typically made after the acute setting when the window for acute treatment has closed. Patients with stroke mimics who are eligible for tPA may safely be treated with a minimal risk of intracranial hemorrhage.

Hemorrhagic stroke is associated with high morbidity and mortality. A common cause of intracerebral hemorrhage (ICH) is hypertension. Patients with suspected ICH should be immediately evaluated with computed tomography (CT) scanning. If coagulopathic, correction of coagulopathy must be instituted rapidly. Hemorrhage due to hypertension usually occurs in subcortical locations. In patients with atrial fibrillation and ICH, a careful analysis of each individual’s risks and benefits must be performed prior to resuming anticoagulation for ischemic stroke prevention. Prevention involves aggressive blood pressure control.

Migraine may mimic stroke, but acute migraine can also be a (rare) cause of stroke, particularly in the posterior circulation. This risk is particularly high in patients who experience migraine aura, or in those who are smokers or who take oral contraceptives. Because this is a diagnosis of exclusion, other etiologies of stroke need to be investigated. Although there are no high-level clinical trial data, it is advised to control vascular risk factors and avoid medications that can potentially induce vasoconstriction in patients with migraine-related stroke.

Carotid dissection should be considered as a stroke etiology, especially in young patients with a history of trauma. Carotid dissection can be recognized by exam findings and radiographic studies. Treatment can include aspirin or anticoagulation.

Intracranial aneurysms may be detected incidentally on imaging. Location and size of an intracranial aneurysm are helpful in stratifying risk of hemorrhage. Risk stratification is important for treatment decision-making. Modifiable risk factors associated with aneurysm growth and rupture (hypertension and tobacco use) should be addressed. Treatment needs to be individualized. Small aneurysms may be monitored. Surgery has been associated with neurological disability and cognitive impairment. Endovascular coiling may be associated with a higher rate of incomplete obliteration. There are no randomized trial data in patients with unruptured aneurysms.

Carotid stenosis is a risk factor for stroke. Revascularization of high-grade asymptomatic carotid stenosis in select patients can lower the risk of incident stroke. Endarterectomy and stenting are both associated with periprocedural risk. Risks and benefits need to be evaluated carefully before proceeding with any intervention. Certain patient demographic and clinical characteristics, such as female gender, may reduce the benefits of surgery and influence treatment decisions.

Lacunar strokes are strongly associated with hypertension. Long-term blood pressure management is important after lacunar stroke. Antiplatelet therapy should be instituted for secondary stroke prevention.

Infective endocarditis can cause neurological complications, including stroke, hemorrhage, and mycotic aneurysms. Patients with endocarditis and neurological complications need vascular imaging to evaluate for aneurysm formation. Patients with acute ischemic stroke from septic emboli may not respond to conventional intravenous thrombolysis and have higher rates of hemorrhagic complications.

Sickle cell disease may result in large vessel intracranial stenoses, which cause high rates of stroke. Screening for elevated velocities on transcranial Dopplers is a good way to stratify stroke risk. Patients at high stroke risk should participate in an exchange transfusion program indefinitely to reduce the rate of subsequent stroke. Although there is a high risk of stroke in pediatric sickle cell patients, the use of IV tPA in this population is largely unstudied and not routinely recommended due to unclear safety and efficacy.

Aneurysmal subarachnoid hemorrhage typically causes sudden severe headache. Diagnosis is made by CT scan in most cases, but lumbar puncture may be needed if CT findings are normal and suspicion is high. Rapid evaluation and treatment are important because of the high morbidity and mortality associated with rebleeding and vasospasm.

Occult atrial fibrillation is more common than previously thought in patients with cryptogenic stroke, particularly in older cohorts. If stroke patients are suspected to have atrial fibrillation, intensive cardiac monitoring using implantable loop recorders or prolonged external monitors should be ordered and can result in higher rates of arrhythmia detection.

Advanced cancer is well known to cause a procoagulant state. The formation of sterile platelet thrombin vegetations on cardiac valves (i.e., nonbacterial thromboembolic disease) and arterial thrombosis are common etiologies of stroke in these patients. Despite preventative therapy with antiplatelet agents or low-molecular-weight heparins, stroke in cancer often portends a poor prognosis.

High-grade intracranial atherosclerosis is associated with a high risk of recurrent stroke. Medical therapy with antiplatelet therapy and aggressive risk factor control is the preferred treatment regimen for stroke prevention in patients with intracranial atherosclerosis. Current stenting techniques are associated with high morbidity and mortality.

Atrial fibrillation is a potent risk factor for stroke. Anticoagulation significantly lowers recurrent stroke risk in patients with atrial fibrillation. The novel oral anticoagulants offer options in addition to warfarin, and they are associated with lower risk of bleeding complications.

Patients with symptomatic carotid stenosis benefit from revascularization. The risk of recurrent stroke is highest during the early period after a transient ischemic attack or stroke. Carotid endarterectomy and carotid stenting are options for treatment and should be considered within the first 2 weeks if feasible.

Reversible cerebral vasoconstriction syndrome can cause thunderclap headache, subarachnoid hemorrhage, and stroke. The clinical presentation can be similar to aneurysmal subarachnoid hemorrhage and therefore requires rapid angiography. Angiographic findings of vasculopathy and resolution of clinical symptoms and imaging abnormalities support this diagnosis. This syndrome is most often incited following pregnancy or the ingestion of a vasoactive medication.

There are many modifiable risk factors for stroke. Screening for risk factors in the primary care setting and instituting early lifestyle modification or medical treatment of risk factors will lower the risk of incident stroke.

Transient ischemic attack (TIA) is a risk factor for subsequent stroke. A TIA diagnosis should incorporate findings on brain MRI and noninvasive angiography, if available. Some patients with TIA are at high risk of early recurrence. Rapid evaluation and treatment reduce that risk. Some new data suggest that short-term dual antiplatelet therapy may reduce stroke recurrence in patients with TIA or minor stroke.

Atherosclerosis of the ascending aorta and arch can potentially lead to high rates of embolic stroke. Evaluating plaque elements for complexity on transesophageal echocardiogram can help stratify this risk of stroke. Either antiplatelets or anticoagulants can be used for stroke prevention.

The presence of a patent foramen ovale (PFO) is associated with cryptogenic stroke, especially in young patients. Medical therapy for patients with stroke and PFO includes antiplatelet therapy or anticoagulation. PFO closure is not routinely recommended for stroke prevention.

BACKGROUND AND PURPOSE: Antiplatelet drug resistance has been associated with thromboembolic complications in patients after coronary stent placement. It has not been well-studied in patients who have neurovascular stent-placement procedures. This study aimed to analyze the relationship between antiplatelet drug resistance and neurovascular stent-placement complications. MATERIALS AND METHODS: A prospective data base of all patients treated at our institution was used to identify patients with neurovascular stent-placement procedures. During a 4.5-year period, all patients undergoing neurovascular stent placement were evaluated for aspirin and clopidogrel resistance by using the VerifyNow assay. During an observational phase, all patients received 75 mg of clopidogrel and aspirin (group A). During the intervention phase (group B), patients were given additional clopidogrel on the basis of the clopidogrel resistance assay. We assessed the development of thromboembolic complications within 30 days of the procedure in patients who were resistant-versus-nonresistant to clopidogrel. RESULTS: Of 96 patients who had neurovascular stent placement, 5.2% were resistant to aspirin and 36.5% were resistant to clopidogrel. Periprocedural thromboembolic complications were seen in 7 patients (7.3%). In a multivariate logistic regression model, clopidogrel resistance, higher diastolic blood pressure, and lack of statin use were significantly associated with periprocedural thromboembolic complication. There was a nonsignificant decrease in thromboembolic complications in patients whose clopidogrel dosage was tailored to the assay. CONCLUSIONS: In our series, clopidogrel resistance was associated with increased periprocedural thromboembolic complications from neurovascular stent-placement procedures. Targeting the clopidogrel dose to platelet inhibition assays may improve clinical outcomes and requires further study.

Stroke is the third leading cause of death and the leading cause of disability in the United States. Stroke incidence is clearly associated with advancing age. Although younger adults are at lower risk, stroke in this population has a particularly high public health impact because of associated indirect costs, such as longer years of lost productivity.There have been many epidemiological studies addressing race ethnic differences in overall stroke incidence and mortality, but few specifically examining these differences in the young adult population. There is evidence that race ethnic differences may have a greater effect on stroke incidence and mortality in young adults. An understanding of these differences may help better identify high risk populations and focus preventative strategies. Furthermore, analysis of race/ethnic differences in stroke subtypes may help clarify mechanisms of stroke in young adults and potential race-ethnic differences in early stroke risk factors.

Purpose of review The results of recent large clinical trials have modified treatment plans formerly based on inferred mechanisms of ischemic stroke and hazards of certain forms of therapy. Recent findings Strong data have emerged to support anticoagulation with warfarin for stroke associated with inferred embolism in a setting of atrial fibrillation. No clear advantage for warfarin over aspirin exists for ischemic stroke in a setting of intracranial atheroma, patent cardiac foramen ovale, or elevated levels of antiphospholipid antibody. Among antiplatelet agents, aspirin and clopidogrel have a similar recurrent stroke risk. Combination therapies with aspirin and warfarin show no additional benefits with regard to stroke prevention and carry higher risks of hemorrhage. Treatment with aspirin combined with specially formulated long-acting dipyridamole carries a lower risk of stroke than aspirin alone and does not increase the risk of hemorrhage significantly. The combination of aspirin and clopidogrel does not reduce the risk of stroke over clopidogrel alone and carries a greater risk of bleeding than clopidogrel alone. Summary Choice of antithrombotic therapy depends on the etiology of the stroke. Oral anticoagulation treatment is the preferred choice for inferred cardioembolism in the setting of atrial fibrillation, while the varying rates of hemorrhage with oral anticoagulants continue to favor antiplatelet therapy in other settings of inferred etiology. Combinations of antithrombotic therapy vary in their lowering of stroke rate, and some raise the risk of hemorrhage. Insufficient data exist to determine whether antithrombotic therapy combined with antihypertensives, statins or other agents will further reduce the risk of stroke in synergistic or supplemental fashion, or give no additional benefit.

There are few data available regarding the safety or efficacy of thrombolysis of acute ischemic stroke secondary to myxoma. We present a patient treated with intravenous recombinant tissue plasminogen activator who developed hemorrhage remote from the location of ischemic stroke. Intra-arterial local thrombolysis may be a preferable alternative because of greater risk of hemorrhage from occult tumor emboli or microaneurysms in these patients.

Background and Purpose— The SSS-TOAST is an evidence-based classification algorithm for acute ischemic stroke designed to determine the most likely etiology in the presence of multiple competing mechanisms. In this article, we present an automated version of the SSS-TOAST, the Causative Classification System (CCS), to facilitate its utility in multicenter settings. Methods— The CCS is a web-based system that consists of questionnaire-style classification scheme for ischemic stroke (http://ccs.martinos.org). Data entry is provided via checkboxes indicating results of clinical and diagnostic evaluations. The automated algorithm reports the stroke subtype and a description of the classification rationale. We evaluated the reliability of the system via assessment of 50 consecutive patients with ischemic stroke by 5 neurologists from 4 academic stroke centers. Results— The kappa value for inter-examiner agreement was 0.86 (95% CI, 0.81 to 0.91) for the 5-item CCS (large artery atherosclerosis, cardio-aortic embolism, small artery occlusion, other causes, and undetermined causes), 0.85 (95% CI, 0.80 to 0.89) with the undetermined group broken into cryptogenic embolism, other cryptogenic, incomplete evaluation, and unclassified groups (8-item CCS), and 0.80 (95% CI, 0.76 to 0.83) for a 16-item breakdown in which diagnoses were stratified by the level of confidence. The intra-examiner reliability was 0.90 (0.75–1.00) for 5-item, 0.87 (0.73–1.00) for 8-item, and 0.86 (0.75–0.97) for 16-item CCS subtypes. Conclusions— The web-based CCS allows rapid analysis of patient data with excellent intra- and inter-examiner reliability, suggesting a potential utility in improving the fidelity of stroke classification in multicenter trials or research databases in which accurate subtyping is critical.

Background: We aimed to identify the rate of major neurologic improvement (MNI) at 24 h following endovascular recanalization therapy (ERT) for acute ischemic stroke and its association with short-term outcome. Methods: We retrospectively reviewed consecutive acute ischemic stroke patients presenting to our institution over 4 years and undergoing ERT. Angiograms were independently reviewed. Data on demographics, medical history, initial NIHSS score, 24-hour NIHSS score, site of acute vascular lesion, pre- and posttreatment Thrombolysis in Myocardial Infarction scores, symptomatic intracerebral hemorrhage (within 36 h of intervention that was associated with a 4-point decline in NIHSS score) and discharge disposition were collected. We used logistic regression analysis to identify predictors of MNI (defined as ≥8-point improvement in NIHSS or a score of 0–1 at 24 h) and favorable discharge status (defined as home or acute rehabilitation). Results: Sixty-eight patients were included (median age = 71 years, 60% women, median NIHSS score = 19.5, anterior circulation = 75%). The modes of ERT were pharmacologic only (28%), mechanical only (35%) and multimodal therapy (37%). Thrombolysis in Myocardial Infarction 2 or 3 recanalization was achieved in 64.7% (mechanical only 46%, pharmacologic only 63% and multimodal 84%). The outcomes were: symptomatic intracerebral hemorrhage (11.8%), MNI (26.5%) and favorable discharge (41.2%). Age (OR = 0.93, p = 0.003) and cardioembolic stroke subtype (OR = 6.0, p = 0.018) were independent predictors of MNI. MNI was a strong predictor of favorable discharge status (OR = 46.4, p < 0.001). Conclusions: Despite initial stroke severity, MNI occurred in over one fourth of the patients and independently and strongly predicted favorable discharge outcome.

Patent foramen ovale is a common finding in the general population. It is associated with an increased risk of stroke, but it may not have a significant effect on recurrent stroke risk in medically treated patients. Recently, many questions have arisen with respect to best treatment for preventing recurrent stroke. Some data from a clinical trial of anticoagulation compared with antiplatelet therapy support antiplatelet treatment for secondary prevention. There are not enough data currently to support surgical or percutaneous closure of patent foramen ovale for stroke prevention.

Objective To characterize short-term prognoses among patients with transient ischemic attack (TIA) and normal diffusion-weighted imaging (DWI) results, TIA patients with abnormal DWI results (transient symptoms associated with infarction [TSI]), and patients with completed ischemic stroke (IS). Design Retrospective study. Setting University hospital. Patients We reviewed patient medical records between January 2003 and December 2004 with International Classification of Diseases, Ninth Revision codes for TIA at admission, resolution of neurological symptoms within 24 hours, magnetic resonance imaging within 48 hours, and a discharge diagnosis of TIA or IS. A random sample of 50 IS patients was selected from all IS admissions and discharges by International Classification of Diseases, Ninth Revision codes. Demographic, clinical, radiographic, and in-hospital outcome data were recorded. Three diagnostic categories were created: TIA with normal DWI results, TSI, and IS. Multivariate logistic regression was used to estimate the association between diagnostic category and rate of in-hospital stroke or recurrent TIA among the 3 groups. Results We identified 146 classic TIA (25% with TSI) and 50 IS cases. There were 4 recurrent TIAs and 6 strokes among patients with TSI (27.0%); 3 recurrent TIAs and no strokes among patients with normal DWI results (2.8%); and 1 recurrent stroke and no TIAs among IS patients (2.0%). Transient symptoms associated with infarction was independently associated with in-hospital recurrent TIA or stroke (adjusted odds ratio, 11.2; P Conclusions Transient symptoms associated with infarction is associated with a greater rate of early recurrent TIA and stroke than both IS and TIA with normal DWI results. These data suggest that TSI may be a separate clinical entity with unique prognostic implications.