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Introduction Atherosclerotic cervical internal carotid artery disease is one of the major causes of ischemic stroke and transient ischemic attacks. The risk of stroke from mild to moderate stenoses (i.e., < 50% stenosis) might be underestimated, and further investigation is mandated to describe the association between high‐risk plaque features and ESUS. Methods This was a retrospective observational study. Using the stroke registry of our hospital’s system between June 20th 2016 and June 20th 2021. We reviewed data for patients diagnosed with ESUS according to previously published definition criteria. Using computed tomography angiography (CTA), we analyzed laterality of high‐risk plaque features in relation to the stroke side, and then we identified the incidence of recurrent stroke events. Results Out of 1779 patients with cryptogenic ischemic stroke, only 152 met the inclusion criteria for ESUS. We Compared high‐risk plaque features ipsilateral to stroke side as to contralaterally. There were significantly more ulcerations defined as >1 mm depression (19.08% vs 5.26%, p< .0001), plaque thickness >3 mm (19.08% vs 7.24%, p = 0.001), and plaque length >1cm (13.16% vs 5.92%, p = 0.0218).Also, there was a significant difference in stenosis of ipsilateral to stroke when compared contralaterally, especially for stenoses of 10–30% and 31–49% (17.76% vs 10.53% and 5.26% vs 2.63%, respectively. p = 0.0327). There was also a significant difference in plaque component; both components (soft and calcified) and only soft plaque (42.76% vs 23.68% and 17.76% vs 9.21%, respectively. p< .0001) were more prevalent ipsilaterally. In total, 17patients were found to have a recurrent stroke event, 8 patients had an ipsilateral stroke to the index event, 7 had a bilateral and 2 had a contralateral event. Conclusions ESUS is more commonly found ipsilateral to high‐risk plaque features. Qualitative assessment of plaque features using CTA could be easily implemented in clinical practice. The small number of our sample is definitely a limitation. Further large and multicenter studies aiming to form precise prediction models and scoring systems are needed to help guide treatment with carotid artery stenting or carotid endarterectomy versus maximizing medical therapy.

Introduction The secondary prevention of Acute ischemic stroke (AIS)varies based on the root cause of the initial event; thus, determining the cause of an individual AIS is critical for implementing effective care. The well‐described TOAST classification is used to classify stroke etiology, and according to this paradigm, the presence of large vessel disease is considered a high risk for subsequent stroke only if >50% carotid artery stenosis is present. Cryptogenic strokes represent around 30% of all AIS and Embolic stroke of unknown source (ESUS) is a subcategory of the cryptogenic strokes and is characterized as a non‐lacunar ischemic stroke presumed to be of an embolic origin with no evidence of an obvious source of emboli. Here we discuss the most important and latest evidence on the relationship between ESUS and high‐risk plaque features not causing significant stenosis per NASCET criteria. Methods N/A Results The Relationship Between ESUS and Non‐stenosing Carotid Artery Plaques is mainly illustrated in the following points: Plaque vulnerability Researchers have described the following high‐risk features of plaques that may lead to stroke (Table). Plaque vulnerability is a plaque’s susceptibility to rupture and is a proposed determinant of high risk for superimposed thrombosis. According to a meta‐analysis conducted by Kamtchum‐Tatuene et al, high‐risk plaque features were three times more prevalent in patients with symptomatic versus asymptomatic carotid stenosis.3 Laterality of cartid plaques and stroke A meta‐analysis of 8 studies that assessed 323 patients with ESUS showed that mild carotid stenosis with high‐risk plaque features was more commonly located ipsilateral to the stroke side (32.5%) versus being contralaterally located (4.6%).4 Knight‐Greenfield et al evaluated plaque features by CTA in patients with AIS who did not have hemodynamic stenosis. It was also found that ESUS patients had a higher total plaque thickness ipsilateral to the stroke side when compared to the contralateral stroke‐free hemisphere.5 Clot composition and stroke etiology Fibrin/platelet component was dominant in cardioembolic thrombi and cryptogenic stroke, while red blood cells were seen more frequently in non‐cardioembolic thrombi. This supports the hypothesis that plaque histological features play a major role in causing large vessel occlusion despite the absence of significant stenosis.8 Conclusions Despite the evidence that high‐risk plaque features can predict a recurrent stroke, adoption of this principle and its integration into the medical guidelines have not yet been established. This reflects a lack of clinical trials that have utilized detailed plaque characterization for assessing risk of stroke.

Introduction Continued advancements in the treatments for neurological disease have helped interventionalists to refine approaches that offer improved surgical efficacy and patient outcomes. Carotid‐artery stenting (CAS) is a safe and effective alternative to carotid endarterectomy (CEA), that allows for revascularization of the internal carotid artery (ICA) in a minimally‐invasive manner. Traditionally, the mainstay for CAS has been through the femoral artery; however, patients with carotid‐artery disease (CAD) often have concomitant peripheral artery disease which confer increased risk of significant life‐threatening access‐site complications, such as retroperitoneal hematoma and limb ischemia. Given this, CAS via the radial artery has become increasingly popular. This study seeks to investigate the safety and feasibility of the transradial approach (TRA), in comparison to the traditional transfemoral approach (TFA), for carotid‐artery stenting. Methods The authors conducted a retrospective analysis of all adult patients (age >18) who underwent carotid‐artery stenting via TRA or TFA over a 4‐year study period (2018‐2021) across 4 different international academic centers. Important variables, such as patient demographics, comorbidities, procedural details, results, and complications were collected. Statistical analysis was performed to assess the strength of association and correlation for these variables. Results A total of 313 patients were enrolled during the study period. CAS via TFA was attempted in 251 patients and via TRA in 62 patients, respectively. Overall, CAS via TRA was found to be successful in 48/62 (76%) patients, and via TFA in 246/251 (98%) patients. Baseline demographics were similar for the two groups, with a female gender predilection, median age of 69, and hypertension and hyperlipidemia serving as the most common medical comorbidities. 14/62 (22.6%) patients who underwent TRA were converted to TFA. Spasm of the radial artery, kinking of the catheter and severe tortuosity of the vessels were the primary reasons for access site conversion. A total of five major access site‐related complications, including two deaths, and seven minor complications were noted in the TFA cohort. No serious access related complications were noted in the TRA group. In the multivariate‐analysis, after adjusting for age, hyperlipidemia, chronic heart failure, combination of stent plus angioplasty and fluoroscopy times, there was no statistically significant difference observed among the 2 groups in terms of procedural (OR: 0.31; CI: 0.36‐2.69; P = 0.29) and overall access site complications (OR: 0.17, CI: 0.02‐1.98, P = 0.16). Conclusions TRA seems to be a safe alternative approach for carotid stenting. In our cohort, no serious access site‐related complications were noted with TRA in comparison to the TFA group. Continued improvements in terms of patient selection, sample size, as well as advances in technique and technology will help to further refine TRA for CAS. Further studies and analysis will need to be performed to delineate the crucial variables that contribute to improved functional outcomes for these patients.

Introduction Ischemic stroke is a neurological disease that affects people worldwide, and it occurs when there is a loss of blood to the brain due to either an artery burst or blood clot. The COVID‐19 pandemic has negatively impacted stroke treatment, specifically mechanical thrombectomy, across the world but especially in Latin and Central America. The objective of this research project is to determine the barriers that COVID‐19 has imposed on stroke treatment in the Latin America region. Methods First, data was collected from articles through NCBI and local news. The data on COVID‐19 and stroke provided input on the number of COVID‐19 cases in Latin America and the overall rate of stroke incidences in each region. Then, the countries in Latin America were divided into three different groups to determine which regions had the most Covid cases, sub‐optimal stroke treatments, and more well‐known health resources. Mexico was zeroed in on as the central region because more data and stroke resources were readily available. A survey was created which contained critical questions on the overall situation of stroke in Mexico and potential barriers, and these surveys were emailed to neurologists and other physicians who were experts in the region. Ultimately, two physicians from Mexico agreed to be interviewed, and important information was received on the status of stroke treatment in these areas. Results From the surveys and interviews, the two doctors revealed important information regarding the specific barriers to stroke treatment. The first doctor interviewed is a physician in a tertiary medical center for specialized neurological conditions. She raised concern about the lack of awareness among the general population about the early recognition of stroke and its symptoms. Additionally, she indicated that her center has the necessary endovascular equipment to offer mechanical thrombectomies, but patients are often unable to reach the hospital on time. Ambulances have been typically unavailable or delayed as they have been prioritized for transporting COVID patients. Additionally, there has been a lack of rehabilitation resources for stroke patients during the pandemic due to the shortage of beds and staff. The second doctor interviewed was additionally concerned about the lack of timely use of equipment for mechanical thrombectomies. When a patient is in need of thrombectomy treatment, the doctor has to contact the intermediary vendor, who brings the equipment for use, hence delaying treatment. He also stated that during the pandemic, a third of the beds were occupied by COVID patients, limiting the availability of hospital beds for other illnesses. Conclusions In conclusion, the COVID‐19 pandemic has negatively impacted stroke treatment in Mexico. The main barriers to stroke treatment include the limited awareness among the general population about the recognition of stroke, a lack of sufficient rehabilitation services, insufficient medical thrombectomy services and the delayed ambulance response. Based on this data, the intervention we are developing is an app that will display stroke‐specific resources and information. This platform will include information on how to recognize stroke, specific stroke‐care hospitals in the region, and helplines.

Introduction It is estimated that 7.6 million Americans report having had a stroke. Every year, approximately 795,000 people develop a stroke, of which 610,000 are for the first time. Although stroke incidence rates in adults ≥ 65 years of age decreased by 32% per decade from 1987 to 2017, it remains both the fifth leading cause of death and the leading cause of disability in the United States1. Ischemic strokes make up 87% of all strokes and can be categorized by the TOAST classification scheme. Etiologies include large‐vessel atherosclerosis, small vessel disease, cardioembolism, stroke of other determined etiology, and stroke of undetermined etiology2. Cardioembolic strokes, accounting for up to 25% of ischemic strokes typically involve a cardiac insult resulting from either atrial disease, valvular heart disease, structural and functional ventricular diseases, or myocardial infarction. The most common etiology of cardioembolic stroke and focus of this study is atrial fibrillation3. Stroke of undetermined etiology, also called cryptogenic stroke accounts for nearly 30% of ischemic strokes and has been recently coined in the literature as embolic stroke of undetermined source (ESUS) due to the presence of embolic features in the majority of these cases. Atrial cardiomyopathy has been identified as a contributing cause to ESUS with the detection of atrial fibrillation sometimes after original classification4. Though a significant portion of ESUS patients are found to have atrial fibrillation, it is not often detected on presentation. Additionally, ESUS patients can present with a large‐vessel occlusion (LVO), often with a high initial NIHSS. It may be of benefit to compare ESUS patients with and without LVO on the basis of detection of atrial fibrillation. Methods This study is a retrospective cohort study of patients discharged from the Neurology general practice unit, Stroke step‐down unit, or Neurosurgical ICU from January 2014 to June 2022.Subject charts will be reviewed for the following variables: 1)Demographics: Age, race, sex, 2)Use of antithrombotics, 3)Specific antithrombotics prescribed, 4)Stroke etiology, 5)Initial NIHSS, 6)Presence of large vessel occlusion (LVO), 7)Received tPA, 8)Received MER, 9)Detection of atrial fibrillation, 10)Detection of arrhythmia, 11)Presence of reduced ejection fraction, 12)Received Holter monitor, 13)Underwent internal loop recorder placement, 14)Recurrence of stroke or TIA. Results ESUS patients often present with atrial fibrillation. ESUS patients can present with a large‐vessel occlusion (LVO). There was a higher rate of detection of atrial fibrillation in patients with ESUS who present with LVO in comparison to patients with ESUS who do not present with LVO. Conclusions This study demonstrated that there may be an increased likelihood of atrial fibrillation in patients with ESUS who present with LVO versus those who do not present with LVO. Areas of further development include prevention of LVO‐related ischemic stroke in patients with atrial fibrillation, targeted LVO education for patients with atrial fibrillation, earlier initiation of anticoagulant stroke preventive medication for high‐risk LVO patients. The study may also help elucidate whether extended cardiac monitoring would be beneficial for patients who present with an LVO.

Background During the COVID-19 pandemic, decreased volumes of stroke admissions and mechanical thrombectomy were reported. The study’s objective was to examine whether subarachnoid haemorrhage (SAH) hospitalisations and ruptured aneurysm coiling interventions demonstrated similar declines.Methods We conducted a cross-sectional, retrospective, observational study across 6 continents, 37 countries and 140 comprehensive stroke centres. Patients with the diagnosis of SAH, aneurysmal SAH, ruptured aneurysm coiling interventions and COVID-19 were identified by prospective aneurysm databases or by International Classification of Diseases, 10th Revision, codes. The 3-month cumulative volume, monthly volumes for SAH hospitalisations and ruptured aneurysm coiling procedures were compared for the period before (1 year and immediately before) and during the pandemic, defined as 1 March–31 May 2020. The prior 1-year control period (1 March–31 May 2019) was obtained to account for seasonal variation.Findings There was a significant decline in SAH hospitalisations, with 2044 admissions in the 3 months immediately before and 1585 admissions during the pandemic, representing a relative decline of 22.5% (95% CI −24.3% to −20.7%, p