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ObjectiveTo test the hypothesis that race-, age-, and sex-specific incidence of cerebral venous thrombosis (CVT) has increased in the United States over the last decade.MethodsIn this retrospective cohort study, validated ICD codes were used to identify all new cases of CVT (n = 5,567) in the State Inpatients Databases (SIDs) of New York and Florida (2006–2016). A new CVT case was defined as first hospitalization for CVT in the SID without prior CVT hospitalization. CVT counts were combined with annual Census data to compute incidence. Joinpoint regression was used to evaluate trends in incidence over time.ResultsFrom 2006 to 2016, annual age- and sex-standardized incidence of CVT in cases per 1 million population ranged from 13.9 to 20.2, but incidence varied significantly by sex (women 20.3–26.9, men 6.8–16.8) and by age/sex (women 18–44 years of age 24.0–32.6, men 18–44 years of age 5.3–12.8). Incidence also differed by race (Blacks: 18.6–27.2; Whites: 14.3–18.5; Asians: 5.1–13.8). On joinpoint regression, incidence increased across 2006 to 2016, but most of this increase was driven by an increase in all age groups of men (combined annualized percentage change [APC] 9.2%, p < 0.001), women 45 to 64 years of age (APC 7.8%, p < 0.001), and women ≥65 years of age (APC 7.4%, p < 0.001). Incidence in women 18 to 44 years of age remained unchanged over time.ConclusionCVT incidence is disproportionately higher in Blacks compared to other races. New CVT hospitalizations increased significantly over the last decade mainly in men and older women. Further studies are needed to determine whether this increase represents a true increase from changing risk factors or an artifactual increase from improved detection.

Key Points Question Which processes of care are associated with reduced risk of mortality or recurrent stroke after transient ischemic attack or nonsevere ischemic stroke? Findings In this cohort study of 8076 patients with transient ischemic attack or nonsevere ischemic stroke, only 1216 (15.3%) received without-fail care, defined as receiving all guideline-concordant processes of care for which they were eligible (ie, brain imaging, carotid artery imaging, antihypertensive intensification, high- or moderate-potency statin therapy, antithrombotics, and anticoagulation for atrial fibrillation). Receiving all 6 processes was associated with lower risk of death (31.2% reduction at 1 year) but not lower risk of recurrent stroke. Meaning Clinicians should ensure that patients with transient ischemic attack and nonsevere ischemic stroke receive all guideline-concordant processes of care for which they are eligible., This cohort study identifies processes of care that are associated with reduced risk of death or recurrent stroke among patients with transient ischemic attack or nonsevere ischemic stroke., Importance Early evaluation and management of patients with transient ischemic attack (TIA) and nonsevere ischemic stroke improves outcomes. Objective To identify processes of care associated with reduced risk of death or recurrent stroke among patients with TIA or nonsevere ischemic stroke. Design, Setting, and Participants This cohort study included all patients with TIA or nonsevere ischemic stroke at Department of Veterans Affairs emergency department or inpatient settings from October 2010 to September 2011. Multivariable logistic regression was used to model associations of processes of care and without-fail care, defined as receiving all guideline-concordant processes of care for which patients are eligible, with risk of death and recurrent stroke. Data were analyzed from March 2018 to April 2019. Main Outcomes and Measures Risk of all-cause mortality and recurrent ischemic stroke at 90 days and 1 year was calculated. Overall, 28 processes of care were examined. Without-fail care was assessed for 6 processes: brain imaging, carotid artery imaging, hypertension medication intensification, high- or moderate-potency statin therapy, antithrombotics, and anticoagulation for atrial fibrillation. Results Among 8076 patients, the mean (SD) age was 67.8 (11.6) years, 7752 patients (96.0%) were men, 5929 (73.4%) were white, 474 (6.1%) had a recurrent ischemic stroke within 90 days, 793 (10.7%) had a recurrent ischemic stroke within 1 year, 320 (4.0%) died within 90 days, and 814 (10.1%) died within 1 year. Overall, 9 processes were independently associated with lower odds of both 90-day and 1-year mortality after adjustment for multiple comparisons: carotid artery imaging (90-day adjusted odds ratio [aOR], 0.49; 95% CI, 0.38-0.63; 1-year aOR, 0.61; 95% CI, 0.52-0.72), antihypertensive medication class (90-day aOR, 0.58; 95% CI, 0.45-0.74; 1-year aOR, 0.70; 95% CI, 0.60-0.83), lipid measurement (90-day aOR, 0.68; 95% CI, 0.51-0.90; 1-year aOR, 0.64; 95% CI, 0.53-0.78), lipid management (90-day aOR, 0.46; 95% CI, 0.33-0.65; 1-year aOR, 0.67; 95% CI, 0.53-0.85), discharged receiving statin medication (90-day aOR, 0.51; 95% CI, 0.36-0.73; 1-year aOR, 0.70; 95% CI, 0.55-0.88), cholesterol-lowering medication intensification (90-day aOR, 0.47; 95% CI, 0.26-0.83; 1-year aOR, 0.56; 95% CI, 0.41-0.77), antithrombotics by day 2 (90-day aOR, 0.56; 95% CI, 0.40-0.79; 1-year aOR, 0.69; 95% CI, 0.55-0.87) or at discharge (90-day aOR, 0.59; 95% CI, 0.41-0.86; 1-year aOR, 0.69; 95% CI, 0.54-0.88), and neurology consultation (90-day aOR, 0.67; 95% CI, 0.52-0.87; 1-year aOR, 0.74; 95% CI, 0.63-0.87). Anticoagulation for atrial fibrillation was associated with lower odds of 1-year mortality only (aOR, 0.59; 95% CI, 0.40-0.85). No processes were associated with reduced risk of recurrent stroke after adjustment for multiple comparisons. The rate of without-fail care was 15.3%; 1216 patients received all guideline-concordant processes of care for which they were eligible. Without-fail care was associated with a 31.2% lower odds of 1-year mortality (aOR, 0.69; 95% CI, 0.55-0.87) but was not independently associated with stroke risk. Conclusions and Relevance Patients who received 6 readily available processes of care had lower adjusted mortality 1 year after TIA or nonsevere ischemic stroke. Clinicians caring for patients with TIA and nonsevere ischemic stroke should seek to ensure that patients receive all guideline-concordant processes of care for which they are eligible.

Background: The importance of physical activity in preventing major vascular events has received increased attention in the past decade. Due to the inclusion of the INTERVENT lifestyle modification program, the CREST2 trial provides a unique opportunity to study physical activity profiles in patients with severe asymptomatic extracranial carotid stenosis. Hypothesis: Based on data from a trial of intracranial stenosis patients, we aimed to evaluate the hypothesis that Methods: We analyzed 1087 CREST2 participants with baseline data on physical activity. The Physician-based Assessment and Counseling for Exercise (PACE) score is recorded for each patient and dichotomized as “in target” (4-8 points) or “out of target” ( Results: The mean age of the study population is 69.5±7.8 years (60% male). The median PACE score at baseline is 4.0 (mean 3.8±2.1; IQR 2 to 6). The Table shows baseline characteristics of patients by mean PACE score. Being male, not having diabetes mellitus, having a body mass index Conclusions: We have defined several patient groups with asymptomatic carotid stenosis that have suboptimal physical activity. These results provide opportunities for targeted efforts to improve primary stroke prevention. These baseline data will also allow investigators to determine if trial involvement and the INTERVENT program leads to improvement in the level of physical activity.

Background: Atrial Fibrillation (AF) is the leading cause of embolic stroke and is associated with a 5-fold increased risk of stroke. Currently, less than 50% of high-risk patients are receiving a prescription for oral anticoagulants (OACs). Guidelines for Primary Prevention of Stroke recommend the emergency department (ED) as an important location for physicians to identify patients with AF and start them on OACs. Methods: A retrospective review was completed of AF patients in the ED from 2014-2018 at a large health system. The prevalence of OAC prescription was identified in three different cohorts: 1) patients discharged from the ED, 2) those admitted under observation status and discharged within 48 hours, and 3) those admitted to inpatient. CHA 2 D 2 -VASc scores were calculated and risk factors were reviewed. Results: We identified 438 patients: 106 in the ED cohort, 132 in the observation cohort and 200 in the inpatient cohort. The average age was 63.1. 77.9% had hypertension and 46.35% were women. The average CHA 2 D 2 -VASc score was 2.45 in the ED cohort, 2.56 in the observation cohort and 3.35 in the inpatient cohort. ED physicians addressed AF in 77% of the ED cohort. Out of the high-risk patients (CHA 2 D 2 -VASc score ≥ 2) discharged from the ED, 17% were newly prescribed an OAC compared to 74% of patients who were admitted under observation status and 78% of patients admitted to inpatient. (7/40 [17.5%] vs 39/53 [73.6%]; p Conclusions: Patients with AF are more likely to be prescribed an OAC if admitted to inpatient or under observation status compared to the ED. There were many missed opportunities in the ED to start patients on OACs. Further studies should identify barriers to OAC prescription in the ED to implement better practice strategies.

Background: Oral anticoagulant (OAC) for atrial fibrillation use remains underutilized despite evidence in favor of its utility. In a three-center study examining the efficacy of a technological intervention to improve OAC use, two sites were randomly selected to incorporate an embedded alert in the electronic health record (EHR) while the third site provided usual care. At the intervention sites, the EHR calculated each patient’s CHA 2 DS 2 -VASc score and alerted the clinician when OAC therapy was recommended. We aimed to investigate whether this system increased OAC use in elderly patients. Methods: Patient medication was tracked at the time of hospitalization, discharge, and within 30 days of discharge. Patients were categorized by age and study arm to assess medication use at last known follow-up via the Chi Square and Fisher’s Exact tests. Results: The control site contained 152 patients, 65 being 75+ years of age, while the two intervention sites contained 164 patients, also with 65 patients who were 75+ years of age. Those aged 75+ show statistically significant proclivity for prior strokes (2 DS 2 -VASC score was 4 in the elderly group and 2 in the younger group (p Conclusions: Despite increased CHA 2 DS 2 -VASc scores, we did not demonstrate the benefit of electronic alerts among elderly AF patients. Additional research is needed regarding methods to overcome therapeutic inertia in this area. Study support: Boehringer-Ingelheim

Objective: Prevalence of alcohol abuse (AA) in the United States (US) is on the increase. AA patients may develop alcohol withdrawal (AW) during hospitalization, but it remains unknown how AW influences acute ischemic stroke (AIS) outcome. Methods: All adult AIS admissions in the US from 2004–2014 were identified from the National Inpatient Sample (NIS) (weighted N=4,438,968). Multivariable-adjusted models were used to evaluate the association of AW with in-hospital medical complications, mortality, cost, and length-of-stay in patients with AIS. Results: During this period, 3.9% of all AIS admissions had comorbid codes for AA but prevalence differed significantly by age; 10.6% of AA patients, representing 0.4% of all AIS, developed AW. Prevalence of AA and AW in AIS increased by 45.2% and 40.0%, respectively, over time (p-value for trend 50% increased odds of urinary tract infection, pneumonia, sepsis, gastrointestinal bleeding, deep venous thrombosis, and acute renal failure compared to those without AW. Patients with AW were also 32% more likely to die during their AIS hospitalization compared to those without AW (OR 1.32, 95% CI 1.11–1.58). AW was associated with 15-day increase in length-of-stay and $5,000 increase in hospitalization cost (p-values Conclusions: AW is associated with increased cost, longer hospitalizations, and higher odds of medical complications and in-hospital mortality following AIS. Proactive surveillance and management of AW may be important in improving outcomes in these patients.

Background: CHA2DS2-VASc score is used for stroke risk stratification in atrial fibrillation patients. We considered the possible use of the CHA2DS2Vasc score to predict perioperative stroke and subsequent stroke risk in patients undergoing CAS for symptomatic or asymptomatic atherosclerotic carotid disease. Methods: CAS Patients were identified from a prospectively collected neuroendovascular database maintained at our institution. We then collected the demographic information and the elements necessary to calculate the CHA2DS2vasc score. Primary outcomes were stroke within 30 days of the procedure and during follow-up. Mortality due to stroke and all-cause mortality were secondary outcomes. Patients were stratified into three groups based on their CHADVASC score. 0-3 (low risk), 4-6 (moderate risk) and 7-9 (high risk). We then compared the clinical outcomes amongst the three groups and high risk group was used as a reference during multivariate analysis. Results: From January 2010 to June 2018, 210 patients underwent CAS at our institution but after excluding patients with tandem lesions and radiation induced carotid stenosis,161 patients were included in the analysis [mean age 67 ± 25 years, 52 (32 %) were women]. Among the patients, 26 (16%) patients had CHA2DS2Vasc-score 0-3, 100 (62 %) in 4-6 group and 35 (22 %) in 7-9 group. A total of 10 (6.2%) had perioperative stroke and 4 (2.5 %) patients had perioperative death. Mean follow-up time was 17 months (range 0-96). Higher number perioperative strokes were observed in the patients with CHADVASC score 7-9 compared to moderate and low risk groups [(14% versus 3% versus 11.5 %) respectively; p-value 0.016]. Similarly recurrent stroke rate was significantly higher in high risk group compared to the other two [31.4% vs 4% vs 3.8% respectively); p-value Conclusion: In this analysis of CAS patients, higher CHA2DS2Vasc-Score predicted the increased perioperative and recurrent stroke risk. This should be validated further in large registries and trials of CAS patients.

Background Large vessel occlusion (LVO) strokes can in part be prevented with better atrial fibrillation (AF) stroke prevention strategies; thus we evaluated the rate of AF in patients presenting with acute LVO strokes undergoing mechanical thrombectomy (MT) and assessed patterns of oral anticoagulant (OAC) use prior to the index stroke. Methods and Results We identified 347 MT cases from February 2015 to September 2018. A retrospective chart review was conducted to identify patient sociodemographics, presence of AF, use of anticoagulation, stroke severity, CHA2DS2-VASc scores, and functional outcomes. AF was present in 161 (46%) cases. Patients with AF were older (mean 76 ± 11 years vs. 66 ± 15 years) and more likely to be female (56% vs. 46%) with higher rates of hypertension, dyslipidemia, heart failure and smoking. Of the 100 patients with known AF, 59 were not on anticoagulation prior to the index stroke. Of 39 patients with known AF on OAC, 57% were not therapeutic on warfarin and 20% were not taking prescribed direct OACs. A total of 72 (21%) thrombectomy cases were performed on patients with known AF who were not effectively anticoagulated. After multivariate adjustments, there was no significant difference in modified Rankin Scale score at discharge, in-hospital mortality, or symptomatic intracranial hemorrhage between the AF and non-AF groups. Conclusion In our study, 21% of patients with LVO stroke had known AF and were not effectively anticoagulated. Improved stroke preventive measures could potentially reduce the occurrence of stroke and avoid unnecessary procedures for patients with AF.

Guidelines for the primary prevention of stroke recognize the emergency department as a location for physicians to identify atrial fibrillation and to initiate oral anticoagulants. Numerous studies have shown low anticoagulant prescription rates-approximately 18%-in OAC-naïve patients with atrial fibrillation discharged from the emergency department. We sought to obtain the opinions of Emergency Medicine physicians regarding anticoagulant decision-making for patients with atrial fibrillation seen in the emergency department.14-item paper surveys were distributed to emergency department physicians within a single hospital system. The survey consisted of single-, multi- answer and open-ended questions regarding knowledge and usage frequency of the CHA55 emergency department physicians completed the survey (overall response rate 59%). 89% (49/55) agreed the emergency department is an important location to initiate anticoagulation depending on comorbidities. A lower proportion reported ever starting a patient in the emergency department on a new anticoagulant prescription upon discharge (55% (30/55) p.0001). The belief that a new anticoagulant prescription is the responsibility of the PCP/ Cardiologist/ Neurologist (52%; 15/29), not wanting to be held responsible in the event of a life-threatening bleeding event (41%; 12/29), and concerns about inadequate follow-up and/or lack of insurance (24%; 7/29) were the most commonly cited reasons for not starting an appropriate patient with atrial fibrillation on an anticoagulant.Emergency Medicine physicians support initiating oral anticoagulants in the ED for patients with atrial fibrillation; however, discrepancies exist between their intentions and actual practice.

To evaluate trends in atrial fibrillation (AF) prevalence in acute ischemic stroke (AIS) and TIA in the United States.We used the Nationwide Inpatient Sample to retrospectively compute weighted prevalence of AF in AIS (n = 4,355,140) and TIA (n = 1,816,459) patients admitted to US hospitals from 2004 to 2013. Multivariate-adjusted models were used to evaluate the association of AF with clinical factors, mortality, length of stay, and cost.From 2004 to 2013, AF prevalence increased by 22% in AIS (20%-24%) and by 38% in TIA (12%-17%). AF prevalence varied by age (AIS: 6% in 50-59 vs 37% in ≥80 years; TIA: 4% in 50-59 vs 24% in ≥80 years), sex (AIS: male 19% vs female 25%; TIA: male 15% vs female 14%), race (AIS: white 26% vs black 12%), and region (AIS: Northeast 25% vs South 20%). Advancing age, female sex, white race, high income, and large hospital size were associated with increased odds of AF in AIS. AF in AIS was a risk factor for in-hospital death (odds ratio 1.93, 95% confidence interval 1.89-1.98) but mortality in AIS with AF decreased from 11.6% to 8.3% (p0.001). Compared to no AF, AF was associated with increased cost of $2,310 and length of stay 1.1 days in AIS.AF prevalence in AIS and TIA has continued to increase. Disparity in AF prevalence in AIS and TIA exists by patient and hospital factors. AF is associated with increased mortality in AIS. Innovative AIS preventive strategies are needed in patients with AF, especially in the elderly.

Extracranial (EC) and intracranial (IC) large vessel atherosclerosis account for about 20% of ischemic stroke cases. In recent years, new treatments have emerged for treatment of both EC and IC disease.The stroke rate in patients with carotid stenosis is decreasing with modern medical therapy. For patients with asymptomatic stenosis, the stroke rate is likely1% per year. Some subsets of patients with symptomatic carotid disease benefit less from revascularization, and medical management can be considered in these patients. A second clinical trial has confirmed that aggressive medical management is the treatment of choice for IC atherosclerotic disease. Vessel wall imaging may be useful to define pathophysiology in patients with IC stenosis and could ultimately help tailor therapy, but further studies are needed. Medical therapy is preferred to stenting for patients with vertebral artery-origin stenosis.Recent data and emerging concepts regarding large vessel atherosclerosis are provided.

BackgroundPrevious clinical trials have suggested that carotid-artery stenting with a device to capture and remove emboli (“embolic protection”) is an effective alternative to carotid endarterectomy in patients at average or high risk for surgical complications. MethodsIn this trial, we compared carotid-artery stenting with embolic protection and carotid endarterectomy in patients 79 years of age or younger who had severe carotid stenosis and were asymptomatic (i.e., had not had a stroke, transient ischemic attack, or amaurosis fugax in the 180 days before enrollment) and were not considered to be at high risk for surgical complications. The trial was designed to enroll 1658 patients but was halted early, after 1453 patients underwent randomization, because of slow enrollment. Patients were followed for up to 5 years. The primary composite end point of death, stroke, or myocardial infarction within 30 days after the procedure or ipsilateral stroke within 1 year was tested at a noninferiority margin of 3 p...

BackgroundIn the Carotid Revascularization Endarterectomy versus Stenting Trial, we found no significant difference between the stenting group and the endarterectomy group with respect to the primary composite end point of stroke, myocardial infarction, or death during the periprocedural period or any subsequent ipsilateral stroke during 4 years of follow-up. We now extend the results to 10 years. MethodsAmong patients with carotid-artery stenosis who had been randomly assigned to stenting or endarterectomy, we evaluated outcomes every 6 months for up to 10 years at 117 centers. In addition to assessing the primary composite end point, we assessed the primary end point for the long-term extension study, which was ipsilateral stroke after the periprocedural period. ResultsAmong 2502 patients, there was no significant difference in the rate of the primary composite end point between the stenting group (11.8%; 95% confidence interval [CI], 9.1 to 14.8) and the endarterectomy group (9.9%; 95% CI, 7.9 to 12.2)...

To evaluate the development and management of cerebrovascular risk factors following a pregnancy with preeclampsia.This is a retrospective chart review including women diagnosed with preeclampsia between 2012 and 2013 with later encounters within 2014-2016. For each subject that met inclusion criteria, the development of cerebrovascular risk factors was determined using ICD codes within the 2014-2016 electronic medical record (EMR). For subjects who developed risk factors, current treatment was determined from the EMR. Demographic data was also documented. Differences in the development and treatment of risk factors were compared among racial groups and age. Descriptive statistics were calculated using SAS statistical software.Compared to prepregnancy health status, the incidence of hypertension increased by 1.7 times (P.05), hyperlipidemia increased by 4.5 (P.05), migraines increased by 2.2 (P.05), and diabetes mellitus increased by 2 (P.05) after a pregnancy with preeclampsia. Black non-Hispanics had highest rates of hypertension, obesity, and migraines (20.5%, 9.1%, and 6.8%, respectively.) Of hypertensives, 73.6% (42/57) were prescribed medication. Of diabetics, 88.9% (16/18) were prescribed medication. No patients with hyperlipidemia were prescribed a statin. Black non-Hispanics had higher rates of risk factor management (74.3% of hypertensives and 100% of diabetics treated) than white Hispanics (55% and 77.8%, respectively).This study shows a significant increased risk of the development of cerebrovascular risk factors such as hypertension, hyperlipidemia, migraines, and diabetes following a diagnosis of preeclampsia. Opportunities exist for the early treatment of these risk factors, which could reduce the long-term rate of stroke in these women.

Background and aim Atrial Fibrillation is the leading cause of embolic stroke, yet less than half of high-risk patients with atrial fibrillation are on adequate stroke prevention with oral anticoagulants. Guidelines for the primary prevention of stroke recognize the emergency department as a location for physicians to identify atrial fibrillation and initiate anticoagulants. We sought to compare anticoagulant prescription rates in patients with atrial fibrillation in various provider settings to identify opportunities for improvement in cardioembolic stroke prevention. Methods A retrospective cohort study of 436 patients with atrial fibrillation presenting to the emergency department from 2014 to 2018 was performed. Baseline characteristics, stroke risk, and rates of anticoagulant prescription were compared across 3 groups: (1) patients discharged from the emergency department, (2) patients admitted under observation status, and (3) patients admitted to inpatient hospital service. Results Among 436 patients (47% women, 51% Hispanic), we identified 105 in the emergency department cohort, 131 in the observation cohort and 200 in the inpatient cohort. The average CHA2DS2-VASc score was 2.5 in the emergency department cohort, 2.6 in the observation cohort and 3.3 in the inpatient cohort. Anticoagulants were prescribed for high-risk patients (CHA2DS2-VASc score ≥ 2) in 17.5% (7/40) of the emergency department cohort compared to 73% (38/52, P Conclusion Patients with atrial fibrillation are more likely to be prescribed anticoagulants if admitted to inpatient or under observation status compared to the emergency department.

Having more than one-third of the world's 7.6 billion population, China and India experience heavy personal, social, and financial costs of stroke and other vascular disease, in the context of having a high prevalence of background vascular risk and rapidly evolving demography (aging, urbanization), lifestyles (sedentary, diet), and economies. However, their differing health care systems and insurance schemes may influence the patterns of care and recovery from stroke, but to date, no one has directly quantified this. The article by Li et al.1 in this issue of Neurology ® is therefore a welcome contribution to defining the comparative patient profile, as well as the management and outcomes, for acute ischemic stroke (AIS) between these 2 countries.

We thank Dr. Hsieh for the interest in our study that investigated prevalence of vascular risk factors in stroke patients.1

Purpose of reviewThe incidence of stroke in young adults is increasing, mainly driven by an increasing incidence of ischemic stroke in this population. We provide new information that has been recently presented regarding the risk factor prevalence, some specific etiologic causes, and management strategies in ischemic stroke in this population.Recent findingsRecent studies indicate a rapid increase in traditional risk factors in young adults. New information regarding the management of patent foramen ovale in cryptogenic stroke and cervical artery dissection is available.SummaryStroke in young adults is a rapidly growing problem with deep public health implications. There are many areas in this field, which require further research.

The vision of thrombolysis for reversal of acute ischemic stroke (AIS) was launched in 1958,1 but it was not until 1995 that 2 landmark studies, one in Europe2 and the other in the United States,3 established IV administration of tissue plasminogen activator (tPA) as an effective treatment for AIS. The National Institute of Neurological Disorders and Stroke study, with a 3-hour treatment window from onset of symptoms to vein puncture, showed more efficacy and had fewer safety concerns than the original European Cooperative Acute Stroke Study (ECASS) trial that had designated 6 hours from symptom onset as the limit for IV infusion of tPA. Since 1995, the administration of IV tPA to reverse the ravages of AIS has become the standard and only validated form of treatment.4 So much has been published, discussed, commented, editorialized and publicly aired about IV tPA in AIS that one would assume that IV tPA is a universally available form of treatment. In a recent poster presentation at the 65th annual meeting of the American Academy of Neurology (AAN), a group of investigators from the United States5 reported the global use of IV tPA for AIS by country, income group, and country-level health expenditure per capita. The researchers conducted a systematic review in PubMed from 1997 to 2012. Each country's publications in any language were reviewed and the results were startling. Of 214 countries and independent territories, 54 (25%) reported use of IV tPA for AIS. In relation to income status, the study revealed IV tPA usage in 3% (1/36) of low-income countries, 13% (7/54) of lower-middle-income countries, 28% (15/54) of upper-middle-income countries, and 44% (31/70) of high-income countries. The authors concluded that IV tPA for AIS has limited use globally, is available to patients in only one-quarter of countries in the higher income brackets, and that barriers to IV tPA use for countries at different income levels must be understood to be overcome. Ironically, stroke incidence might be increasing in lower-income countries6 as traditional risk factors for stroke become increasingly prevalent in those countries.

Background: In CREST2, intensive medical management of subjects’ vascular risk factors is overseen by the site Principal Investigator (PI) and implemented by a designated Medical Management Physician (MMP) and coordinator. These physicians have different specialties and experience with risk factor management. We sought to determine the relationship between risk factor control and PI and MMP specialty. Methods: Data on 613 patients with at least 1 follow-up visit from 105 CREST2 sites were used for these analyses. CREST2 sites were categorized based on both PI specialty and MMP specialty. Specialty of the site-designated primary MMP was used for sites with more than one MMP. We compared the percentage of patients in target at last follow-up visit for the primary risk factors, LDL < 70 mg/dL and SBP Results: The table shows the number of patients by PI and MMP specialty, as well as their control of SBP and LDL. There were no significant differences in control of SBP or LDL by PI specialty. There was a trend toward an association between LDL control and MMP specialty, with higher rates of LDL control at sites with Internal Medicine MMP specialists and lower rates of control with Vascular Surgery MMPs. SBP control rates were not significantly different across MMP specialties. Conclusions: In this early analysis of risk factor control in the CREST2 study, site PI and MMP specialty did not have a significant effect on LDL and SBP during follow-up. This suggests that protocol care pathways are generalizable to diverse physicians.

Background: Data on trends in intravenous thrombolysis (tPA) and mechanical thrombectomy (MT) in acute ischemic stroke (AIS) patients are outdated. We aim to: (1) Evaluate current age and sex-specific trends in tPA and MT usage following AIS in the USA (2) Compare in-hospital mortality and moderate-to-severe disability between men and women following tPA and/or MT. Methods: A total of 4,579,246 admissions was identified with the diagnosis of AIS from 2004-2014 using the National Inpatient Sample (NIS). Patients receiving IV tPA and/or MT were identified using ICD-9 procedural codes and Medicare Diagnosis-related Group codes. Weights provided in the NIS were used to compute overall unadjusted weighted frequency of IV tPA and MT in subgroups characterized by age and sex. Multivariate models were used to evaluate trends in tPA and MT usage in both sexes and to assess their association with in-hospital mortality and moderate-to-severe disability. Results: Across the study period from 2004 to 2014, tPA use increased by >300% in both men (1.8% to 8.0%) and women (1.3% to 7.7%) but by 2014 marked disparity still existed by age (figure 1). MT use also increased by >300% from 2004-2014 in both sexes (males 0.1% to 2.1% versus females 0.1 to 1.8%) but proportion of younger patients (18-39 years) receiving MT was higher compared to other age groups in both men and women (figure 1). After multivariable adjustment, there is no significant difference in MT amongst either sex, but women were less likely to receive IV tPA (OR 0.92, 95%CI 0.90-0.94, p Conclusion: TPA and MT use has increased significantly in the USA over the last decade but disparities in tPA usage and outcome by age and sex still exist.

All patients with evidence of internal carotid artery or vertebral artery atherosclerotic disease should be treated with medical therapy to stabilize and hopefully prevent the progression of the atherosclerotic disease process. In practice, this includes several facets. This includes antithrombotic therapies to prevent thrombus formation and the subsequent risk of transient ischemic attack or ischemic stroke. In addition, cholesterol lowering with statin medication is recommended to help prevent disease progression. Blood pressure control is also important to retard ongoing vascular injury. Lifestyle modification such as smoking cessation and increased physical activity is also recommended.

Preview All transient ischemic attacks are not created equal. However, they are a medical emergency, and all patients should be hospitalized for urgent evaluation of their risk for stroke or myocardial infarction. For optimal management, it must be determined whether an ischemic attack affects the anterior or posterior circulation. In this article, the authors review current medical options for stroke prevention and the indications for carotid endarterectomy.

Background and Purpose— The Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) medical group had a much lower primary end point rate than predicted from the preceding Warfarin Aspirin Symptomatic Intracranial Disease (WASID) trial. This result has been attributed to the aggressive medical therapy used in SAMMPRIS, but an alternative hypothesis is that SAMMPRIS patients were at lower risk. We undertook analyses to evaluate these competing hypotheses. Methods— Using proportional hazards regression, we compared the SAMMPRIS primary end point between SAMMPRIS medical patients and WASID patients meeting the same qualifying criteria adjusted for confounding baseline characteristics. Results— The unadjusted comparison of the SAMMPRIS primary end point showed a significantly higher risk for WASID patients ( P =0.009, logrank test) with 12 month Kaplan–Meier estimates of 21.9% in WASID and 12.6% in SAMMPRIS and hazard ratio 1.9 (95% confidence interval =1.2–3.0). The analyses identified the following confounding factors that varied between the studies and that conferred a higher risk: lack of statin use at enrollment (hazard ratio =1.8, 95% confidence interval =1.1–2.9, P =0.027) that was more prevalent among WASID patients (39% versus 14%, P P =0.023) that was more prevalent among SAMMPRIS patients (34% versus 22%, P =0.015).The hazard ratio for WASID versus SAMMPRIS adjusted for these 2 characteristics was 1.9 (95% confidence interval =1.1–3.2). Conclusions— After adjustment for confounding baseline characteristics, WASID patients had an almost 2-fold higher risk of the SAMMPRIS primary end point, which supports the hypothesis that the lower rate of the primary end point in the medical arm of SAMMPRIS compared with WASID patients was as a result of the aggressive medical management used in SAMMPRIS. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00576693.

Carotid atherosclerosis accounts for approximately 10% of ischemic stroke cases. Multifaceted medical therapy reduces the risk of stroke in patients with carotid stenosis. Revascularization with endarterectomy or stenting can benefit select patients. In recent years, new information has been obtained regarding optimal selection of revascularization candidates. In addition, new concepts have been formulated regarding the relationship between carotid stenosis and vascular cognitive impairment. Finally, the declining rate of stroke with improved medical therapy has led to the launch of new clinical trials to determine the contemporary risk/benefit ratio of revascularization relative to aggressive medical therapy.

Given the known association between migraines and risk of ischemic stroke (IS)1–3 along with a lack of understanding of the mechanism by which migraine leads to increased IS risk, we read with great interest the recent article by van Os et al,4 investigating the association between migraine and cerebrovascular atherosclerosis. Using data from over 600 patients with IS (53 with migraine) from the Dutch Acute Stroke Study, authors compared cerebrovascular atherosclerotic burden measured with computed tomographic angiography between patients with and without a history of migraine. The primary findings of the study do not indicate an association between migraine and excess large-vessel atherosclerosis. This article is an important addition to the current body of …

With the greater availability of treatments for acute ischaemic stroke, including advances in endovascular therapy, personalised assessment of patients before treatment is more important than ever. Women have a higher lifetime risk of stroke; therefore, reducing potential sex differences in the acute stroke setting is crucial for the provision of equitable and fast treatment. Evidence indicates sex differences in prevalence and types of non-traditional stroke symptoms or signs, prevalence of stroke mimics, and door-to-imaging times, but no substantial differences in use of emergency medical services, stroke knowledge, eligibility for or access to thrombolysis or thrombectomy, or outcomes after either therapy. Women presenting with stroke mimics or non-traditional stroke symptoms can be misdiagnosed, which can lead to inappropriate triage, and acute treatment delays. It is essential for health-care providers to recognise possible sex differences in stroke symptoms, signs, and mimics. Future studies focused on confounders that affect treatment and outcomes, such as age and pre-stroke function, are also needed.

The purpose of the study was to update the recent information pertaining to carotid artery stenosis risk stratification and treatment. Current decision-making related to carotid artery stenosis is based on clinical trials that are outdated. Medical therapy has improved considerably in the past two decades, and this has reduced the stroke rate for both symptomatic and asymptomatic carotid stenoses. In recent community-based studies, the stroke risk with asymptomatic stenosis has been

Rationale Trials conducted decades ago demonstrated that carotid endarterectomy by skilled surgeons reduced stroke risk in asymptomatic patients. Developments in carotid stenting and improvements in medical prevention of stroke caused by atherothrombotic disease challenge understanding of the benefits of revascularization. Aim Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial (CREST-2) will test whether carotid endarterectomy or carotid stenting plus contemporary intensive medical therapy is superior to intensive medical therapy alone in the primary prevention of stroke in patients with high-grade asymptomatic carotid stenosis. Methods and design CREST-2 is two multicenter randomized trials of revascularization plus intensive medical therapy versus intensive medical therapy alone. One trial randomizes patients to carotid endarterectomy plus intensive medical therapy versus intensive medical therapy alone; the other, to carotid stenting plus intensive medical therapy versus intensive medical therapy alone. The risk factor targets of centrally directed intensive medical therapy are LDL cholesterol Study outcomes The primary outcome is the composite of stroke and death within 44 days following randomization and stroke ipsilateral to the target vessel thereafter, up to four years. Change in cognition and differences in major and minor stroke are secondary outcomes. Sample size Enrollment of 1240 patients in each trial provides 85% power to detect a treatment difference if the event rate in the intensive medical therapy alone arm is 4.8% higher or 2.8% lower than an anticipated 3.6% rate in the revascularization arm. Discussion Management of asymptomatic carotid stenosis requires contemporary randomized trials to address whether carotid endarterectomy or carotid stenting plus intensive medical therapy is superior in preventing stroke beyond intensive medical therapy alone. Whether carotid endarterectomy or carotid stenting has favorable effects on cognition will also be tested. Trial registration United States National Institutes of Health Clinicaltrials.gov NCT02089217

The “Time is brain” concept should be familiar to anyone who cares for patients with acute ischemic stroke. IV tissue plasminogen activator (tPA) reduces disability after stroke when administered within 4.5 hours of symptom onset, but the benefit of IV tPA is time-dependent.1 Earlier treatment improves functional outcomes. Quantified many ways, studies provide estimates in terms of functional outcome at 90 days, neurons saved, and days of disability-free life gained.1–3 As a result, door-to-needle time, defined as the time from hospital arrival to the initiation of IV tPA, has become an important quality metric for stroke hospitals around the world.

Background and Purpose— Multicenter clinical trials attempt to select sites that can move rapidly to randomization and enroll sufficient numbers of patients. However, there are few assessments of the success of site selection. Methods— In the CREST-2 (Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trials), we assess factors associated with the time between site selection and authorization to randomize, the time between authorization to randomize and the first randomization, and the average number of randomizations per site per month. Potential factors included characteristics of the site, specialty of the principal investigator, and site type. Results— For 147 sites, the median time between site selection to authorization to randomize was 9.9 months (interquartile range, 7.7, 12.4), and factors associated with early site activation were not identified. The median time between authorization to randomize and a randomization was 4.6 months (interquartile range, 2.6, 10.5). Sites with authorization to randomize in only the carotid endarterectomy study were slower to randomize, and other factors examined were not significantly associated with time-to-randomization. The recruitment rate was 0.26 (95% confidence interval, 0.23–0.28) patients per site per month. By univariate analysis, factors associated with faster recruitment were authorization to randomize in both trials, principal investigator specialties of interventional radiology and cardiology, pre-trial reported performance >50 carotid angioplasty and stenting procedures per year, status in the top half of recruitment in the CREST trial, and classification as a private health facility. Participation in StrokeNet was associated with slower recruitment as compared with the non-StrokeNet sites. Conclusions— Overall, selection of sites with high enrollment rates will likely require customization to align the sites selected to the factor under study in the trial. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT02089217.

Background: The Carotid Revascularization Endarterectomy vs. Stenting Trial (CREST) showed greater safety of carotid artery stenting (CAS) in patients (pts) 70 yo. The aim of this study was to evaluate national patterns in CAS performance in pts >70yo in the pre- (2007-2010) and post-CREST (2011-2013) era. Methods: Adults requiring CAS or CEA were identified from the 2007-2013 Nationwide Inpatient Sample (NIS) using International Classification of Disease (ICD-9) codes. We estimated the proportion of CAS performed in all age groups and used multivariate models adjusted for clinical and hospital factors to compare odds of receiving CAS in the pre- to post-CREST era. Results: We identified 839,357 weighted cases of CAS and CEA from the NIS. 15.7% of CAS and 8.4% of CEA were performed in symptomatic pts. CAS increased in all age groups over time (figure 1). Proportion of >70yo receiving CAS increased from 11.9% in the pre- to 13.9% in the post-CREST era (p=0.004). In multivariate models, odds of receiving CAS as opposed to CEA increased by 15% in all pts >70yo in the post-CREST compared to the pre-CREST period (OR 1.15, 95%CI 1.10-1.19, p70yo, while female sex (OR 0.92, 95%CI =0.89-0.97), smoking (OR 0.84, 95%CI 0.79-0.90) and weekend admission (OR 0.78, 95%CI 0.70-0.86) were negatively associated with odds of CAS. Conclusion: Rates of CAS increased in the post- compared to pre-CREST era in pts >70yo including asymptomatic women. Despite the concerns of higher periprocedural complications with CAS in elderly pts, the results of CREST have not influenced clinical revascularization practice in pts >70yo.

Introduction: Obstructive sleep apnea (OSA) severity is an independent predictor of cardiovascular disease (CVD) including stroke. Black race has been associated with higher likelihood of CVD morbidity and lower PAP adherence, an unhealthy patient behavior. Data are equivocal for “healthy user” effect: whether a patient’s regular PAP use is associated with physician behavior of optimal CVD prescription regimen. It is unknown if this relationship varies by patient race. We aim to describe whether the association of PAP use with optimal CVD treatment regimen prescription depended on race in veterans with OSA. Methods: We conducted a cross-sectional study of existing PAP users at a VA Medical Center. Data on demographics, medications, comorbidities, and OSA were collected. Optimal CVD medication regimen required prescription of antiplatelet, antihypertensive, and statin. Objective: PAP use was measured by % of days with use ≥ 4 hours. Using logistic regression, we examined whether the association of patient PAP use with physician optimal medication prescription varied by race. The model included race, PAP use, PAP use by race interaction term, and pertinent covariates. Results: A total of 499 veterans (95% male, 38% Black) were included. Two hundred seventy-three veterans (55%) were prescribed an optimal CVD prevention regimen, while 226 (45%) were prescribed a suboptimal regimen. In logistic regression analyses, older age (OR 1.06, 95% CI 1.0-1.1), Black race (OR 1.8, 95% CI 1.1-2.9), higher BMI (OR 1.1, CI 1.1-1.2), and higher Charlson Index (OR 1.3, 95% CI 1.2-1.5), and PAP use by race interaction term were significantly associated with optimal medication regimen prescription. Among white veterans, level of PAP use was not associated to likelihood of optimal CVD prescriptions regimen; However, among Black veterans, those with high levels of PAP use were significantly more likely to be prescribed optimal medication regimen than individuals with low levels of PAP use. Conclusions: A “healthy user” effect was detected for the relationship between patient PAP adherence and physician optimal CVD regimen prescription in Black, but not white, veterans. Longitudinal studies are needed to determine the temporal order of these health behavior associations.

Background: Interventions that emphasize early evaluation and management of patients with TIA and minor stroke have demonstrated reductions in recurrent vascular events. Objective: To identify processes of care that were associated with reduced risk of recurrent vascular events after TIA or minor stroke. Methods: We identified patients with a TIA or minor stroke cared for in a Department of Veterans Affairs (VA) Emergency Department or inpatient ward (fiscal year 2011). Recurrent vascular events included ischemic stroke, myocardial infarction, heart failure, arrhythmia or death within 90-days and 1-year of discharge. 32 processes of care were examined. Defect-free care was assessed for a set of 6 processes (brain imaging, carotid artery imaging, hypertension management, high or moderate potency statin, antithrombotics, and anticoagulation for atrial fibrillation); patients who received all processes for which they were eligible passed the defect-free measure. Multivariable logistic regression with a random facility effect was used to model recurrent events. Clinically important potential confounders were forced into all models; other significant covariates were identified by backward selection. Results: Among 8107 patients, 14.0% had a recurrent vascular event within 90-days; 26.5% within 1-year. Three processes were associated with lower 90-day events after adjustment for 24 covariates: carotid artery imaging (adjusted OR, 0.74 [95%CI, 0.65-0.85], lipid measurement (0.80 [0.68-0.94]), and anticoagulation quality for atrial fibrillation (0.56 [0.35-0.88]). Three processes were associated with reduced 1-year events: carotid artery imaging (0.80 [0.71-0.89]), lipid measurement (0.85 [0.75-0.97]), and timely carotid stenosis intervention (0.49 [0.26-0.94]). The defect-free care rate, observed in 17.4%, was also associated with a reduction in recurrent vascular event risk both within 90-days (0.78 [0.65-0.93]) and 1-year (0.82 [0.71-0.94]). Conclusions: The delivery of a comprehensive set of clinical processes was associated with clinically meaningful reductions in short and longer-term risk of recurrent vascular events. Widespread implementation of these processes should be strongly considered.

Carotid artery atherosclerotic disease is a well-established risk factor for ischemic stroke. While often asymptomatic, the disease could present with symptoms resulting from low hemodynamic pressure in the carotid system or from emboli arising from carotid plaque. Symptoms typically vary depending on the affected blood vessel: the middle cerebral artery, anterior cerebral artery, or the ophthalmic branch of the internal carotid artery. Symptoms also vary depending on whether the dominant or nondominant hemisphere is involved. Asymptomatic carotid stenosis is picked up incidentally when a bruit is detected on physical examination. In addition to atherosclerosis, other disease processes such as arterial dissection or Moyamoya disease occasionally involve the carotid artery, and are briefly described in this chapter.

A 75-year-old man with a prosthetic mechanical valve presents with a cortical intracerebral hemorrhage and international normalized ratio of 2.7. Magnetic resonance imaging shows 3 to 4 microbleeds (mixed lobar and deep). Should the patient be resumed on warfarin or should off-label use of direct oral anticoagulants be considered? Off-label use of direct oral anticoagulants in intracerebral hemorrhage patients with prosthetic valves. ### Seemant Chaturvedi In this patient, the conventional treatment approach would be to place him back on a vitamin K antagonist (VKA) once the hemorrhage has stabilized and then recommend close monitoring of the international normalized ratio (INR) in the future. However, at times, an unconventional treatment strategy may be best for the patient. In this patient scenario, there are several facts to consider. First, the patient has already bled once in the brain with an INR within the therapeutic range. Second, he has evidence of microbleeds on magnetic resonance imaging, some of which are cortical. This raises concern for potential cerebral amyloid angiopathy. Third, it is known that patients with cerebral amyloid angiopathy have an elevated risk for oral anticoagulant (OAC)–related brain hemorrhage. Given this constellation of facts, it would be wise to discuss with the patient and family the full range of potential treatment options. On the basis of trials in patients with atrial fibrillation, it is established that direct oral anticoagulant (DOAC) medications have a substantially lower risk of intracerebral hemorrhage (ICH) compared with warfarin. The marked reduction in ICH makes DOACs particularly attractive for patients at increased ICH risk. This category includes elderly patients, patients in whom therapeutic anticoagulation is difficult to keep in the proper INR range and patients with prior ICH. Some clinicians may be hesitant to use DOACs in this patient because of the mechanical heart valve and lack of atrial fibrillation. However, patients …

The majority of patients presenting with a stroke or TIA receive imaging for carotid stenosis. Treatment of symptomatic carotid stenosis is familiar to most neurologists since high-profile clinical trials have been conducted in the past. The most well-known in North America is the North American Symptomatic Carotid Endarterectomy Trial (NASCET).1 NASCET and additional analysis by Rothwell et al.2 led to the recommendation that if the patient is an otherwise suitable candidate for carotid endarterectomy (CEA), then performing the operation within 2 weeks of the last symptomatic event is desirable.

Carotid endarterectomy (CEA) remains one of the most commonly performed vascular surgical procedures. Strong, but somewhat outdated data1 demonstrate the benefit of CEA for stroke prevention in select patients with symptomatic and asymptomatic stenosis. Prior investigation and commentary have underscored the effect of surgeon volumes and experience on CEA outcomes. But, what about patient characteristics? In addition to traditional risk stratification factors (symptomatic vs asymptomatic, time of most recent cerebrovascular event, patient sex), do clinicians need to heed other patient variables?

Summary Background The risk of stroke associated with carotid artery restenosis after stenting or endarterectomy is unclear. We aimed to compare the long-term risk of restenosis after these treatments and to investigate if restenosis causes stroke in a secondary analysis of the International Carotid Stenting Study (ICSS). Methods ICSS is a parallel-group randomised trial at 50 tertiary care centres in Europe, Australia, New Zealand, and Canada. Patients aged 40 years or older with symptomatic carotid stenosis measuring 50% or more were randomly assigned either stenting or endarterectomy in a 1:1 ratio. Randomisation was computer-generated and done centrally, with allocation by telephone or fax, stratified by centre, and with minimisation for sex, age, side of stenosis, and occlusion of the contralateral carotid artery. Patients were followed up both clinically and with carotid duplex ultrasound at baseline, 30 days after treatment, 6 months after randomisation, then annually for up to 10 years. We included patients whose assigned treatment was completed and who had at least one ultrasound examination after treatment. Restenosis was defined as any narrowing of the treated artery measuring 50% or more (at least moderate) or 70% or more (severe), or occlusion of the artery. The degree of restenosis based on ultrasound velocities and clinical outcome events were adjudicated centrally; assessors were masked to treatment assignment. Restenosis was analysed using interval-censored models and its association with later ipsilateral stroke using Cox regression. This trial is registered with the ISRCTN registry, number ISRCTN25337470. This report presents a secondary analysis, and follow-up is complete. Findings Between May, 2001, and October, 2008, 1713 patients were enrolled and randomly allocated treatment (855 were assigned stenting and 858 endarterectomy), of whom 1530 individuals were followed up with ultrasound (737 assigned stenting and 793 endarterectomy) for a median of 4·0 years (IQR 2·3–5·0). At least moderate restenosis (≥50%) occurred in 274 patients after stenting (cumulative 5-year risk 40·7%) and in 217 after endarterectomy (29·6%; unadjusted hazard ratio [HR] 1·43, 95% CI 1·21–1·72; p

A recent study found a trend toward increasing hospitalizations for acute ischemic stroke (AIS) among young adults, raising concern for this subgroup. In the present study, we evaluated trends of use of thrombolysis and outcome among young adults (19-44 years of age) with AIS using a nationally representative administrative database.Discharge data were obtained from Nationwide Inpatient Sample between 2001 and 2009. Hospitalizations with a discharge diagnosis of AIS for patients 19 to 44 years of age were included. Use of thrombolysis was determined within this subset. The Cochran-Armitage test was used for trend analysis.Thrombolysis in young patients with AIS increased from 354 (1.84%) in 2001 to 1,237 (4.97%) in 2009 (P.0001). The highest increase was noted at urban teaching hospitals. There was a progressive decrease in mortality in young AIS patients, from 6.81% in 2001 to 5.43% in 2009 (trend P = .027) and significant increase in discharges to rehabilitation (3.42% in 2002 to 12.7% in 2009 [trend P.0001]). Discharge to other facilities decreased significantly (29.1% in 2001 to 17.8% in 2009 [trend P.0001]). The rate of intracranial hemorrhage (2.70% in 2001; 2.69% in 2009) did not show any significant change despite the increase in the use of thrombolysis (trend P = .39).The rate of thrombolysis among young patients with AIS increased significantly between 2001 and 2009. A decrease in deaths with increased rehabilitation placements of young patients with AIS was noted over the last decade, suggesting improving outcomes. The lower rate of use of thrombolysis in rural hospitals may be improved with the widespread use of telestroke.

Racial differences in stroke risk and risk factor prevalence are well established. The present study explored racial differences in the delivery of care to patients with acute stroke between Joint Commission (JC)-certified hospitals and noncertified hospitals. A retrospective chart review was conducted in patients sustaining ischemic stroke admitted to 5 JC-certified centers and 5 noncertified hospitals. Demographic data, risk factors, utilization of acute stroke therapies, and compliance with core measures were recorded. Racial disparities were investigated in the entire group as well as for JC-certified and noncertified hospitals separately. A total of 574 patients (25.1% African Americans) were included. African Americans were significantly younger and more likely to have previous stroke, whereas Caucasians were more likely to have coronary disease and atrial fibrillation. There were no racial differences in other risk factors or baseline functions. Median National Institutes of Health Stroke Scale scores were similar in African Americans and Caucasians, as were proportions receiving intravenous tissue plasminogen activator (tPA) therapy (2.1% in African Americans, 3.5% in Caucasians; P = .40) and intervention (4.2% in African Americans, 6.8% in Caucasians; P = .26). Caucasians were more likely to arrive by emergency medical services (65.5% vs 51.5%; P = .004), to be evaluated by a stroke team (19.1% vs 7.7%; P = .001), and to have a documented National Institutes of Health Stroke Scale score (40.2% vs 29.9%; P = .03). African Americans often did not receive intravenous tPA because of a delay in arrival. African Americans performed better on virtually all stroke care variables in JC-certified centers. JC certification reduced disparity in certain variables, including tPA and deep venous thrombosis prophylaxis administration. Important racial disparities exist in the delivery of several acute stroke care variables. Efforts must be focused on eliminating disparities in prehospital delays. Guideline-based care tendered at JC-certified centers might help narrow disparities in acute stroke care delivery.

Background The Joint Commission (JC) for Accreditation of Healthcare Organizations has devised disease specific certification programs for hospitals, including stroke. JC certification as a primary stroke center (PSC) suggests that the hospital has critical measures in place to ensure improving stroke outcomes over the long term. In this study, we focused on the delivery of care for patients with acute ischemic and compared differences in JC-certified and -noncertified centers in Michigan. Methods We performed a systematic chart review of patients with acute ischemic stroke from 10 Michigan hospitals, half of whom were JC-certified PSCs. Sixty charts were randomly chosen from 1 calendar year from each hospital. An experienced nurse performed the data abstraction, and data analysis was performed with the Fisher exact test. Results A total of 602 charts—of which 302 were from JC-certified PSCs—were chosen for the study. The 2 groups were similar with regard to stroke risk factors except that there were significantly more patients with atrial fibrillation in noncertified centers and there were more African American patients in JC-certified PSCs. Significantly more patients were considered for thrombolytic therapy in JC-certified PSCs compared to noncertified centers (90.4% v 66%; P = .0001). Overall, 3.8% of patients had received thrombolytic therapy without any significant difference between JC-certified PSCs and noncertified centers (4.6% v 3%; adjusted odds ratio 1.64; 95% confidence interval 0.64-4.19; P = .87). However, thrombolysis rates among eligible patients was significantly higher in the JC-certified PSCs (48.2% v 8.8%; P = .0001). The most common reason documented for not giving thrombolytic therapy was late arrival outside the therapeutic window, which was more common in JC-certified PSCs (72.8% v 55.6%; P = .0001) compared to noncertified centers. Seventy-four percent of patients from JC-certified PSCs were discharged home or to inpatient rehabilitation facility compared to 71% ( P = .38) from noncertified hospitals. The mean length of stay was marginally shorter in JC-certified PSCs compared to noncertified centers (5.53 v 6.25 days; P = .08). Conclusions Rates of thrombolysis administration for acute stroke patients across Michigan were low in both JC-certified and noncertified hospitals, although better processes were in place in JC-certified PSCs. While there was no overall difference in the administration of thrombolytic treatment, a greater number of the eligible patients received thrombolysis in the certified centers. There was a tendency to shorter lengths of stay at JC-certified PSCs, but there was no significant difference in discharge to home, inpatient rehabilitation, or inpatient mortality in this study.

Asymptomatic extracranial internal carotid artery atherosclerotic stenosis increases with age and is more common in men. Studies performed more than 2 decades ago showed that carotid endarterectomy reduced the rate of stroke in carefully selected patients with asymptomatic carotid stenosis compared with medical therapy in the long term. Those trials were completed more than 20 years ago and with advances in the treatment of atherosclerotic disease, the question has been raised to as to whether endarterectomy is still of value for patients with asymptomatic narrowing. Perioperative risk of carotid revascularization procedures has also declined. Due to improvements in both medical and surgical treatments for carotid artery stenosis, it is timely to reevaluate the efficacy of carotid intervention relative to medical treatment for patients with asymptomatic stenosis.

Background and Purpose— Data on medical complications after intracerebral hemorrhage (ICH) are sparse. We assessed trends in the prevalence of urinary tract infection, pneumonia, sepsis, deep venous thrombosis (DVT), pulmonary embolism, acute renal failure (ARF), and acute myocardial infarction after ICH in the United States. Methods— A total of 575 211 adult ICH cases were identified from the 2004 to 2013 Nationwide Inpatient Sample. Weighted complication risks were computed by sex and mechanical ventilation status. Multivariate models were used to evaluate trends in complications and assess their association with in-hospital mortality, cost, and length of stay. Results— Overall risks of urinary tract infection, pneumonia, sepsis, DVT, pulmonary embolism, ARF, and acute myocardial infarction after ICH were 14.8%, 7.8%, 4.1%, 2.7%, 0.7%, 8.2%, and 2.0%, respectively, but risk differed by sex and mechanical ventilation status. From 2004 to 2013, odds of DVT and ARF increased, whereas odds of pneumonia, sepsis, and mortality declined over time. All complications were associated with >2.5-day increase in length of stay and >$8000 increase in cost. ARF and acute myocardial infarction were associated with increased mortality in all patients; sepsis and pneumonia were associated with increased mortality only in nonmechanical ventilation patients, whereas urinary tract infection and DVT were associated with reduced mortality in all patients. Conclusions— Despite significant mortality reduction, ARF and DVT risk after ICH have increased, whereas odds of sepsis and pneumonia have declined over the last decade. All complications were associated with increased cost and length of stay, but their associations with mortality were variable, likely due in part to survival bias. Innovative strategies are needed to prevent ICH-associated medical complications.

The treatment approach for patients with internal carotid artery stenosis is receiving increased scrutiny. Major advances in optimal medical therapy have been associated with a declining stroke rate for symptomatic and asymptomatic patients with carotid stenosis. Customising treatment according to gender is worthy of consideration, since earlier clinical trials showed reduced benefit with carotid endarterectomy in women compared to men. In this review, clinical trial results in women are summarised, studies pertaining to carotid plaque imaging in men and women are discussed and new clinical trials are identified. Finally, the rationale for a women's carotid trial is provided.