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Background: Few studies have examined the actual hospital arrival mode, emergency department (ED) care processes, and early outcomes in Hispanic vs non-Hispanic acute ischemic stroke (AIS) patients. We evaluated processes and prognosis by Hispanic ethnicity among AIS patients encountered in urban setting.Methods: We retrospectively reviewed prospectively-collected data on 1,117 AIS patients presenting within 12 hours of ictus to five hospitals in a tertiary-level stroke center network in San Diego, California. Variables of interest included pre-hospital factors, ED care processes, and favorable outcome (day-90 modified Rankin Scale [mRS] score of 0-1); all of which were adjusted for pre-specified covariates in a multivariable logistic regression model.Results: There were 192 Hispanic AIS patients (17.2% of cohort) encountered from June 2004 to March 2011. Hispanic patients were significantly more likely to be younger, female, and diabetic. Hispanic patients arrived by ambulance (vs other arrival modes) less frequently (adjusted OR .56; 95% CI: .38-.81), trended toward a longer time of stroke onset to treatment decision (351.6 vs. 320.02 minutes, P=.07), and experienced a favorable day-90 outcome less often (adjusted OR .52, CI: .28-.96). However, for the day-90 outcome, there was no interaction between ambulance arrival and Hispanic ethnicity (P=.5614).Discussion: Hispanic AIS patients in this study were less likely to arrive at the hospital by ambulance, and experienced half the odds of a favorable outcome compared to others. Strategies to boost ambulance utilization among Hispanic AIS patients and identify contributors to this worrisome outcome disparity are needed. [ABSTRACT FROM AUTHOR]

Background and Purpose: The COVID-19 pandemic has required the adaptation of hyperacute stroke care (including stroke code pathways) and hospital stroke management. There remains a need to provide rapid and comprehensive assessment to acute stroke patients while reducing the risk of COVID-19 exposure, protecting healthcare providers, and preserving personal protective equipment (PPE) supplies. While the COVID infection is typically not a primary cerebrovascular condition, the downstream effects of this pandemic force adjustments to stroke care pathways to maintain optimal stroke patient outcomes., Methods: The University of California San Diego (UCSD) Health System encompasses two academic, Comprehensive Stroke Centers (CSCs). The UCSD Stroke Center reviewed the national COVID-19 crisis and implications on stroke care. All current resources for stroke care were identified and adapted to include COVID-19 screening. The adjusted model focused on comprehensive and rapid acute stroke treatment, reduction of exposure to the healthcare team, and preservation of PPE., Aims: The adjusted pathways implement telestroke assessments as a specific option for all inpatient and outpatient encounters and accounts for when telemedicine systems are not available or functional. COVID screening is done on all stroke patients. We outline a model of hyperacute stroke evaluation in an adapted stroke code protocol and novel methods of stroke patient management., Conclusions: The overall goal of the model is to preserve patient access and outcomes while decreasing potential COVID-19 exposure to patients and healthcare providers. This model also serves to reduce the use of vital PPE. It is critical that stroke providers share best practices via academic and vetted social media platforms for rapid dissemination of tools and care models during the COVID-19 crisis., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: To study the rate of symptomatic intracerebral hemorrhage (SxICH) and major systemic hemorrhage (MSH) after acute stroke treatments among different ethnicities/races., Background: Studies have reported ethnic/racial disparities in intravenous tPA treatment (IV tPA). The adverse outcome of tPA and/or intra-arterial intervention (IA) among different ethnicities/races requires investigation., Methods: We retrospectively reviewed all patients from an IRB-approved registry between June 2004 and June 2018. Patients who received IV tPA, IA, or both for acute stroke were identified and classified into 2 ethnic groups: non-Hispanics or Hispanics (NH/H) and 4 racial groups: Asian, Black, Other (Native Americans and Pacific Islanders), and White (A/B/O/W)., Results: We identified 916 patients that received acute therapy (A/B/O/W: n = 50/104/16/746, H/NH: n = 184/730). For those received IV tPA only (n = 759), IA only (n = 85), and IV tPA+IA (n = 72), the SxICH rate was 4.3%, 4.7%, and 6.9%; the MSH rate was 1.3%, 0%, and 0%, respectively. No significant difference in the rate of SxICH or MSH among different racial or ethnic groups was found after either therapy. Asian race (OR 14.17, P = .01), in association with age, international normalized value (INR), and Partial thromboplastin time (PTT) (OR 1.06, 46.52, and 1.18, P = .020, 0.037, and 0.042, respectively), was predictive of SxICH after IV tPA. There was a significant correlation between age and National Institute of Health Stroke Scale with SxICH (P < .01, P = .02, respectively). Age, INR, and PTT were independent predictors of SxICH after IV tPA (OR 1.06, 46.52, and 1.18, P = .02, 0.04, and 0.04, respectively)., Conclusions: There was no significant difference in the rate of SxICH or MSH after IV tPA, IA, or IV tPA+IA among different racial or ethnic groups. Larger studies are needed to elucidate the race specific causes of SxICH and MSH after acute stroke treatment., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Head computed tomography (CT) is critical for stroke code evaluations and often happens prior to completion of the neurological exam. Eye deviation on neuroimaging (DeyeCOM sign) has utility for predicting stroke diagnosis and correlates with National Institutes of Health Stroke Scale (NIHSS) gaze score. We further assessed the utility of the DeyeCOM sign, without complex caliper-based eye deviation calculations, but simply with a visual determination method., Methods: Patients with initial head CT and final diagnosis from an institutional review board-approved consecutive prospective registry of stroke codes at the University of California, San Diego, were included. Five stroke specialists and 1 neuroradiologist reviewed each CT. DeyeCOM+ patients were compared to DeyeCOM- patients (baseline characteristics, diagnosis, and NIHSS gaze score). Kappa statistics compared stroke specialists to neuroradiologist reads, and visual determination to caliper measurement of DeyeCOM sign., Results: Of 181 patients, 46 were DeyeCOM+. Ischemic stroke was more commonly diagnosed in DeyeCOM+ patients compared to other diagnoses (P = .039). DeyeCOM+ patients were more likely to have an NIHSS gaze score of 1 or higher (P = .006). The NIHSS score of DeyeCOM+ stroke versus DeyeCOM- stroke patients was 8.3 ± 6.0 versus 6.7 ± 8.0 (P = .065). Functional outcomes were similar (P = .59). Stroke specialists had excellent agreement with the neuroradiologist (Κ = .89). Visual inspection had excellent agreement with the caliper method (Κ = .88)., Conclusions: Using a time-sensitive visual determination of gaze deviation on imaging was predictive of ischemic stroke diagnosis and presence of NIHSS gaze score, and was consistent with the more complex caliper method. This study furthers the clinical utility of the DeyeCOM sign for predicting ischemic strokes., (Copyright © 2016 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

Background: Intravenous (IV) Alteplase (tissue plasminogen activator [t-PA]) improves outcome in patients with acute ischemic stroke. Of those with full recovery, some may not have had ischemia. We analyzed the frequency and post-treatment outcomes of stroke code patients with no imaging evidence of stroke to establish the incidence of neuroimaging negative cerebral ischemia (NNCI) and stroke mimics treated with t-PA. In addition, we compared these patients with the group of stroke patients with imaging evidence of acute stroke to determine whether there was a difference in adverse events and functional outcomes., Methods: We included all adult stroke patients treated with IV t-PA within 3 hours of stroke onset from the University of California, San Diego, Specialized Programs of Translational Research in Acute Stroke database through January 2013. The imaging positive stroke (IPS) code group comprised patients with neuroimaging evidence of acute ischemic stroke, whereas the imaging negative stroke code (INS) group included those patients without neuroimaging evidence of acute cerebral ischemia. All final diagnoses were reviewed by an adjudicating body. We reviewed medical records and neuroimaging; compared discharge diagnosis, 90-day modified Rankin Scale (mRS) score, and incidence of intracranial hemorrhage; and adjusted for age, admission National Institutes of Health Stroke Scale (NIHSS), prestroke mRS, and diabetes in multivariable models., Results: We identified 106 patients, 74 IPS patients and 32 INS patients, who had similar baseline characteristics, except for baseline NIHSS (IPS 12.9 ± 8.2, INS 8.0 ± 5.6, P = .002) and incidence of cardiac arrhythmias (IPS 32.4%, INS 12.5%, P = .034). The diagnoses in the INS group were stroke (23, 72%)-representing NNCI, somatization (6, 19%), tumor (1, 3%), seizure (1, 3%), and migraine (1, 3%). All IPS patients were diagnosed with acute ischemic stroke. Adjusted for age, baseline NIHSS, prestroke mRS, and diabetes, the INS patients had significantly higher rates (odds ratio 3.04, P = .036) of good functional outcome (90-day mRS score 0-1). Intracerebral hemorrhage (ICH) was found in 24% of the IPS patients and was symptomatic in 6.8%. None of the INS patients had ICH., Conclusions: Because most INS patients were found to have NNCI, which may represent either transient ischemic attack or aborted stroke, and there were no intracerebral hemorrhages in the INS group, our data support the safety of administering IV t-PA to all patients in whom acute ischemic stroke is clinically suspected. We have demonstrated that NNCI patients and stroke mimics are common, and future larger scale prospective studies are required to delineate the true frequencies of each and to evaluate differences in outcomes., (Copyright © 2014 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

Background: Treating acute ischemic stroke (AIS) within 4.5 hours and door-to-needle time of less than 60 minutes may optimize recovery. It is unknown if onset to Primary Stroke Center (PSC) time goals affect outcome. The purpose of this study was to examine effects of symptom onset to PSC time goals on outcome., Methods: Analysis included prospectively collected data from the University of California San Diego Specialized Program of Treatment Research in Acute Stroke. All AIS patients treated with intravenous recombinant tissue plasminogen activator were included if treated within 270 minutes, and 90-day modified Rankin Scale (mRS) score was known. Primary outcome of the 90-day mRS was analyzed using multivariable logistic regression. Good outcome was defined as a 90-day mRS score of 0-2. Variables assessed were time from onset to arrival, stroke code, neurologic exam, imaging, laboratories, treatment decision, and treatment (by quartiles)., Results: Two hundred ninety-one patients were included (49.8% female, mean age 70.6 ± 16.1, median National Institutes of Health Stroke Scale 10, SD = 8.5). Good outcome occurred in 45% of patients. Significant baseline differences included HTN (P ≤ .001), A fib (P ≤ .001), prestroke mRS (P < .001), and Hispanic ethnicity (P = .011). Comparing good with poor outcome groups: mean onset to arrival was 70.6 min versus 62.5 min (P = .129) and mean onset to treatment was 140.1 min versus 134.9 min (P = .118). Controlling for prespecified covariates, no PSC time goals were significant predictors of the 90-day outcome., Conclusions: In our Comprehensive Stroke Center (CSC), onset to PSC time goals were not significant predictors of the 90-day outcome. Expedited care processes in CSC may compensate for differences in outcome. These results should be validated in a larger cohort and in PSCs versus CSCs., (Copyright © 2014 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

The authors draw on their experience with the University of California, San Diego Medical Center's successful enterprise-level clinical telemedicine program to present a paradigm for other academic health centers (AHCs) that wish to develop such a program. They detail key telemedicine program elements, or "tele-ments," that they consider essential to the development of a centralized, structured telemedicine program and relevant to the development of smaller programs. These tele-ments include an overall organizational vision, a centralized telemedicine infrastructure, telemedicine-specific policies and procedures, medical record documentation, relationships between the AHC clinical hub and its remote (spoke) partners, identification of and training for specialty providers, a business plan based on service agreements and/or insurance billing, and licensure/privileging. They discuss the importance of delaying equipment purchases until a plan is in place for sustaining the telemedicine enterprise and of establishing measures to define success at the outset of program development. In addition, they detail the benefits and concerns associated with telemedicine, provide a comprehensive listing of the roles and responsibilities of providers and staff involved in all aspects of telemedicine, and share samples of their program's informed consent forms and workflow checklists. Their goal is to offer support and guidance to other AHCs entering the telemedicine arena, enabling them to replicate key elements of a successful, enterprise-wide telemedicine infrastructure.

Background and Purpose: To assess the gender differences in patients with acute ischemic stroke treated with and without tissue plasminogen activator. The primary purpose is to evaluate for differences in baseline risk factors, treatment times, and 90-day outcomes. Data regarding gender differences in acute stroke treatment shows a delayed treatment and evaluation in women with stroke, associated with poorer outcome., Methods: Review of the University of California San Diego Specialized Program for Translational Research in Acute Stroke (SPOTRIAS) database from 2001 to 2009. All "code stroke" patients with the admitting diagnosis of acute ischemic stroke were classified based on gender and tissue plasminogen activator treatment (group 1 with tissue plasminogen activator, group 2 without)., Results: A total of 848 patients were included, group 1: 294 patients, baseline median NIHSS and mean age in men was 10 and 67.6+/-16.5 years, in women 13 and 72.4+/-16.5 years. group 2: 554 patients, baseline median NIHSS and mean age in men was 4 and 68.4+/-14.0 years, in women 5 and 72.2+/-14.0 years. Women and men had a similar tissue plasminogen activator treatment rate (women=38%, men=32%). Men were more likely to use tobacco and have a history of coronary artery disease and less likely to have a history of atrial fibrillation. In both groups, men had higher rates of a 90-day modified Rankin scale score of 0 to 1 compared to women (group 1 35.5% vs 22.6%; group 2 57.3% vs 47.3%). Multivariable analysis adjusting for observed confounders, namely admission NIHSS, coronary artery disease/myocardial infarction, and atrial fibrillation, indicate that this difference was not statistically significant. We found no significant difference between genders when assessing for treatment times in either group., Conclusions: Treatment times and patient outcomes after treatment for acute ischemic stroke were similar between genders. Previously identified gender differences in stroke treatment times and outcome were not found in our sample.

Background and Purpose: To prospectively evaluate the reliability and validity of this previously developed stroke scale in an independently collected cohort. The National Institutes of Health Stroke Scale (NIHSS) has been criticized for its complexity and variability. Prior formal clinimetric analyses were used to obtain a modified version of NIHSS (mNIHSS), which retrospectively demonstrated improved reliability and validity. We sought to prospectively measure the reliability and validity of the mNIHSS., Methods: Forty-five patients with a history of stroke or intracerebral hemorrhage were evaluated at the University of California, San Diego, Stroke Center from September 2000 through March 2001. Each patient was tested by 2 NIHSS-certified neurologists using the NIHSS, mNIHSS, Barthel Index, and Modified Rankin scales., Results: There were a large percentage of high kappa values using the mNIHSS. Only 10 (66.67%) of 15 NIHSS kappa scores showed excellent agreement, whereas 10 (90.91%) of 11 mNIHSS kappa scores showed excellent agreement. As predicted, the mNIHSS was more reliable than the NIHSS because of the exclusion of items with low kappa values. With the use of correlation coefficient analysis, the mNIHSS was as valid as the NIHSS., Conclusions: This prospective study found high reliability and continued validity by using a previously developed mNIHSS. Items found to have low kappa values were consistent with the previously derived retrospective mNIHSS. The resulting mNIHSS scale has much higher kappa values. The mNIHSS showed improved agreement between examiners and was also easier to administer, having fewer and simpler items. Further prospective evaluation should assess whether the mNIHSS could be used in lieu of the NIHSS.