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Background and ObjectivesCommunity emergency departments often transfer patients for lack of neurology coverage, potentially burdening patients and accepting facilities. Telestroke improves access to acute stroke care, but there is a lack of data on inpatient teleneurology and telestroke care.MethodsFrom our prospective telestroke registry, we retrospectively reviewed 3702 consecutive patients who were seen via telestroke between September 2015 and December 2018. Patients who required transfer after initial telestroke evaluation or who were kept at hospitals without consistent neurology coverage were excluded from analysis. We compared baseline demographics, clinical characteristics, and hospital outcomes in patients who were subsequently followed remotely by a teleneurology neurohospitalist and those followed in person by a neurohospitalist.ResultsThere were 447 (23%) patients followed by a teleneurology neurohospitalist and 1459 (77%) patients followed in person by a neurohospitalist. Both groups presented with similar stroke severity. In multivariate analysis, there were no significant differences in discharge disposition, stroke readmission rates, or 90-day modified Rankin Scale (mRS) scores. Length of stay was shorter with teleneurology follow-up. In the subgroup of patients who received tissue plasminogen activator, patients showed no differences in outcomes and had similar complication rates. Teleneurology follow-up resulted in a 3% transfer rate for higher level of care after admission. There remained no difference in outcomes in a subanalysis without Comprehensive Stroke Centers. A higher proportion of non-Hispanic Black patients and a lower proportion of Hispanic patients in the teleneurology follow-up group were possibly due to spoke location demographics.DiscussionTeleneurology follow-up resulted in comparable outcomes to in-person neurology follow-up, with few transfers after admission. For select neurology and ischemic stroke patients, teleneurology follow-up provides an alternative to transfer for hospitals lacking neurology coverage.

Background and purpose Previous studies suggest that mechanisms and outcomes in patients with COVID-19-associated stroke differ from those in patients with non-COVID-19-associated strokes, but there is limited comparative evidence focusing on these populations. The aim of this study, therefore, was to determine if a significant association exists between COVID-19 status with revascularization and functional outcomes following thrombectomy for large vessel occlusion (LVO), after adjustment for potential confounding factors. Methods A cross-sectional, international multicenter retrospective study was conducted in consecutively admitted COVID-19 patients with concomitant acute LVO, compared to a control group without COVID-19. Data collected included age, gender, comorbidities, clinical characteristics, details of the involved vessels, procedural technique, and various outcomes. A multivariable-adjusted analysis was conducted. Results In this cohort of 697 patients with acute LVO, 302 had COVID-19 while 395 patients did not. There was a significant difference (p < 0.001) in the mean age (in years) and gender of patients, with younger patients and more males in the COVID-19 group. In terms of favorable revascularization (modified Thrombolysis in Cerebral Infarction [mTICI] grade 3), COVID-19 was associated with lower odds of complete revascularization (odds ratio 0.33, 95% confidence interval [CI] 0.23-0.48; p < 0.001), which persisted on multivariable modeling with adjustment for other predictors (adjusted odds ratio 0.30, 95% CI 0.12-0.77; p = 0.012). Moreover, endovascular complications, in-hospital mortality, and length of hospital stay were significantly higher among COVID-19 patients (p < 0.001). Conclusion COVID-19 was an independent predictor of incomplete revascularization and poor functional outcome in patients with stroke due to LVO. Furthermore, COVID-19 patients with LVO were more often younger and had higher morbidity/mortality rates.

INTRODUCTION: We have demonstrated in a multicenter cohort that the COVID-19 pandemic has led to a delay in intravenous thrombolysis (IVT) among stroke patients. Whether this delay contributes to meaningful short-term outcome differences in these patients warranted further exploration. METHODS: We conducted a nested observational cohort study of adult acute ischemic stroke patients receiving IVT from 9 comprehensive stroke centers across 7 U.S states. Patients admitted prior to the COVID-19 pandemic (1/1/2019-02/29/2020) were compared to patients admitted during the early pandemic (3/1/2020-7/31/2020). Multivariable logistic regression was used to estimate the effect of IVT delay on discharge to hospice or death, with treatment delay on admission during COVID-19 included as an interaction term. RESULTS: Of the 676 thrombolysed patients, the median age was 70 (IQR 58-81) years, 313 were female (46.3%), and the median NIHSS was 8 (IQR 4-16). Longer treatment delays were observed during COVID-19 (median 46 vs 38 min, p = 0.01) and were associated with higher in-hospital death/hospice discharge irrespective of admission period (OR per hour 1.08, 95% CI 1.01-1.17, p = 0.03). This effect was strengthened after multivariable adjustment (aOR 1.15, 95% CI 1.07-1.24, p < 0.001). There was no interaction of treatment delay on admission during COVID-19 (pinteraction = 0.65). Every one-hour delay in IVT was also associated with 7% lower odds of being discharged to home or acute inpatient rehabilitation facility (aOR 0.93, 95% CI 0.89-0.97, p < 0.001). CONCLUSION: Treatment delays observed during the COVID-19 pandemic led to greater early mortality and hospice care, with a lower probability of discharge to home/rehabilitation facility. There was no effect modification of treatment delay on admission during the pandemic, indicating that treatment delay at any time contributes similarly to these short-term outcomes.

BackgroundThe mechanisms and outcomes in coronavirus disease (COVID-19)-associated stroke are unique from those of non-COVID-19 stroke.ObjectiveTo describe the efficacy and outcomes of acute revascularization of large vessel occlusion (LVO) in the setting of COVID-19 in an international cohort.MethodsWe conducted an international multicenter retrospective study of consecutively admitted patients with COVID-19 with concomitant acute LVO across 50 comprehensive stroke centers. Our control group constituted historical controls of patients presenting with LVO and receiving a mechanical thrombectomy between January 2018 and December 2020.ResultsThe total cohort was 575 patients with acute LVO; 194 patients had COVID-19 while 381 patients did not. Patients in the COVID-19 group were younger (62.5 vs 71.2; P < .001) and lacked vascular risk factors (49, 25.3% vs 54, 14.2%; P = .001). Modified thrombolysis in cerebral infarction 3 revascularization was less common in the COVID-19 group (74, 39.2% vs 252, 67.2%; P < .001). Poor functional outcome at discharge (defined as modified Ranklin Scale 3-6) was more common in the COVID-19 group (150, 79.8% vs 132, 66.7%; P = .004). COVID-19 was independently associated with a lower likelihood of achieving modified thrombolysis in cerebral infarction 3 (odds ratio [OR]: 0.4, 95% CI: 0.2-0.7; P < .001) and unfavorable outcomes (OR: 2.5, 95% CI: 1.4-4.5; P = .002).ConclusionCOVID-19 was an independent predictor of incomplete revascularization and poor outcomes in patients with stroke due to LVO. Patients with COVID-19 with LVO were younger, had fewer cerebrovascular risk factors, and suffered from higher morbidity/mortality rates.

Supplemental Digital Content is available in the text., Background and Purpose: The pandemic caused by the novel coronavirus disease 2019 (COVID-19) has led to an unprecedented paradigm shift in medical care. We sought to evaluate whether the COVID-19 pandemic may have contributed to delays in acute stroke management at comprehensive stroke centers. Methods: Pooled clinical data of consecutive adult stroke patients from 14 US comprehensive stroke centers (January 1, 2019, to July 31, 2020) were queried. The rate of thrombolysis for nontransferred patients within the Target: Stroke goal of 60 minutes was compared between patients admitted from March 1, 2019, and July 31, 2019 (pre–COVID-19), and March 1, 2020, to July 31, 2020 (COVID-19). The time from arrival to imaging and treatment with thrombolysis or thrombectomy, as continuous variables, were also assessed. Results: Of the 2955 patients who met inclusion criteria, 1491 were admitted during the pre–COVID-19 period and 1464 were admitted during COVID-19, 15% of whom underwent intravenous thrombolysis. Patients treated during COVID-19 were at lower odds of receiving thrombolysis within 60 minutes of arrival (odds ratio, 0.61 [95% CI, 0.38–0.98]; P=0.04), with a median delay in door-to-needle time of 4 minutes (P=0.03). The lower odds of achieving treatment in the Target: Stroke goal persisted after adjustment for all variables associated with earlier treatment (adjusted odds ratio, 0.55 [95% CI, 0.35–0.85]; P

The coronavirus disease 2019 pandemic has changed the way we engage patient care, with a move toward telemedicine-based health care encounters. Teleneurology is now being rapidly embraced by neurologists in clinics and hospitals nationwide but for many, this paradigm of care is unfamiliar. Exposure to telemedicine in neurology training programs is scarce despite previous calls to expand teleneurology education. Programs that provide a teleneurology curriculum have demonstrated increased proficiency, accuracy, and post-training utilization among their trainees. With the current changes in health care, broad incorporation of teleneurology education in resident and fellow training after this pandemic dissipates will only serve to improve trainee preparedness for independent practice.

Introduction: The AHA 2014 statement on palliative and end-of-life (EOL) care in stroke recommended patient- and family-centered care and goals of care discussions. Despite a recurrent stroke risk of up to 39% at 10 years, stroke survivors have low advance directive completion rates. We conducted a survey characterizing the advance care planning (ACP) attitudes in our population of stroke clinic patients. Methods: We developed a survey based on validated surveys assessing ACP behaviors and engagement. The survey was provided to all TIA, ischemic and hemorrhagic stroke patients in our clinic between February and August 2021. Non-English-speaking patients and those unable to express preferences were excluded. Results: Surveys were provided to 88 stroke survivors with a 68.2% response rate (N=60). Patient characteristics reported in Table 1. Patients were racially and ethnically diverse and 54.2% had greater than high school education. Patients were also fairly independent, most living at home (96.7%) and ambulatory (63.3%). Most patients completed the survey a median of 43 days after their first stroke (63.3%). Less than half (48.3%) of patients had designated a medical decision maker but many (63.3%) had had conversations with family/decision makers about preferences for future medical care if they were to become very sick or near the EOL. However, only 46.7% felt ready to talk with a doctor about these preferences. More than half (53.3%) of patients indicated that they would like their stroke doctor’s participation if/when they were to have such a conversation. Conclusions: In our study group of diverse, younger and more independent stroke survivors, we found that many had had ACP conversations with surrogate decision makers and more than half wanted their stroke doctor to participate in future discussions. More work is needed to assess the generalizability of our findings and how ACP can be improved for stroke survivors who are at high risk for recurrent events.

Introduction : Post‐stroke delirium (PSD) is associated with increased mortality and worse long‐term functional outcomes. Patients who receive reperfusion therapies in the hospital are frequently kept from regular sleep‐wake cycles the first 24 hrs after treatment, and this disruption could lead to an increase in PSD. In this study, we evaluate the effect of PSD on immediate and long‐term outcomes in AIS patients receiving reperfusion therapies. Methods : Between September 2019 and June 2021, patients diagnosed with AIS within 48 hrs of stroke onset were prospectively evaluated for PSD using the Confusion Assessment Method (CAM)‐ICU daily for the first eight days of their hospital stay. Patients with severe stroke and expected mortality within the first month at the time of admission or with severe aphasia unable to follow commands were excluded. Reperfusion therapies were defined as any IV thrombolytic, IA thrombolytic, or mechanical thrombectomy (MT). The primary outcome was considered a 90‐day mRS score of 0–2. Results : Of 179 patients assessed with the CAM‐ICU, 89 (49.7%) had PSD. We identified 94 patients that had undergone one or both reperfusion therapies; 52 (55.3%) had delirium. Patients who received tPa had a higher risk for delirium (42 vs 29, p = 0.04), but no difference was observed with MT (Table 1). Patients with PSD had a longer hospital length of stay and a higher median admission NIHSS. Patients with delirium who received tPA were more likely to be discharged to inpatient rehabilitation facilities than home (p‐value 0.004, OR 10.1 95%CI 2.1,48). No significant difference was found in 90‐day mRs scores of 0–2 in those with or without PSD. Conclusions : AIS patients with PSD after reperfusion therapy had no significant difference in 90‐day good outcomes despite having longer hospital admissions and being less likely to be discharged home. Further evaluation into how reperfusion therapies convey protection to patients is necessary.

Introduction: Our telestroke (TS) network instituted a regional transfer protocol (RTP) that allows for stroke patients in need of higher level of care to be pre-accepted and transferred to the nearest appropriate comprehensive stroke center (CSC). We studied the impact of the RTP on resource utilization and time metrics in patients transferred for evaluation of intra-arterial thrombectomy (IAT). Before the RTP, all potential IAT patients were transferred to one central CSC. After the RTP was initiated, the network had the capability to transfer to two additional CSCs within the same health system that are strategically located in the Houston area. Methods: We identified patients evaluated via TS in spoke emergency rooms that were subsequently transferred for IAT evaluation from 1/1/2016 to 12/31/2017 - one year prior and one year after the RTP. Baseline demographic characteristics, transfer and IAT metrics, and outcomes were compared for the two time periods. Results: Of 220 patients, 102 patients were transferred pre-RTP, and 120 were transferred to the three CSCs post-RTP. There were no significant differences in baseline characteristics, except fewer patients received tPA post-RTP (Table 1). In total, 30 patients (29%) pre-RTP and 42 patients (35%) post-RTP underwent IAT (p=0.38). Post-RTP, there was a trend toward faster travel times (median 40 vs 32 minutes, p=.07) and transfer initiation times to hub arrival times (median 109 vs 100.5 minutes, p=0.09). Door to groin puncture times were not statistically different between the two time periods. Post-RTP patients had a significantly shorter length of stay (median 6 vs 5 days, p=0.03). Conclusions: Regional transfer protocols can potentially help reduce transfer times and length of stay for stroke patients at CSCs that were initially seen by TS at community hospitals; however, larger sample size is needed to study its impact on other IAT-related metrics and clinical outcomes.

© 2020 World Stroke Organization., [Background]: Severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) has been associated with a significant risk of thrombotic events in critically ill patients. [Aim]: To summarize the findings of a multinational observational cohort of patients with SARS-CoV-2 and cerebrovascular disease. [Methods]: Retrospective observational cohort of consecutive adults evaluated in the emergency department and/or admitted with coronavirus disease 2019 (COVID-19) across 31 hospitals in four countries (1 February 2020–16 June 2020). The primary outcome was the incidence rate of cerebrovascular events, inclusive of acute ischemic stroke, intracranial hemorrhages (ICH), and cortical vein and/or sinus thrombosis (CVST). [Results]: Of the 14,483 patients with laboratory-confirmed SARS-CoV-2, 172 were diagnosed with an acute cerebrovascular event (1.13% of cohort; 1130/100,000 patients, 95%CI 970–1320/100,000), 68/171 (40.5%) were female and 96/172 (55.8%) were between the ages 60 and 79 years. Of these, 156 had acute ischemic stroke (1.08%; 1080/100,000 95%CI 920–1260/100,000), 28 ICH (0.19%; 190/100,000 95%CI 130–280/100,000), and 3 with CVST (0.02%; 20/100,000, 95%CI 4–60/100,000). The in-hospital mortality rate for SARS-CoV-2-associated stroke was 38.1% and for ICH 58.3%. After adjusting for clustering by site and age, baseline stroke severity, and all predictors of in-hospital mortality found in univariate regression (p < 0.1: male sex, tobacco use, arrival by emergency medical services, lower platelet and lymphocyte counts, and intracranial occlusion), cryptogenic stroke mechanism (aOR 5.01, 95%CI 1.63–15.44, p < 0.01), older age (aOR 1.78, 95%CI 1.07–2.94, p ¼ 0.03), and lower lymphocyte count on admission (aOR 0.58, 95%CI 0.34–0.98, p ¼ 0.04) were the only independent predictors of mortality among patients with stroke and COVID-19. [Conclusions]: COVID-19 is associated with a small but significant risk of clinically relevant cerebrovascular events, particularly ischemic stroke. The mortality rate is high for COVID-19-associated cerebrovascular complications; therefore, aggressive monitoring and early intervention should be pursued to mitigate poor outcomes.

Introduction: Community emergency departments (EDs) often transfer ischemic stroke (IS) patients for lack of neurology coverage, burdening patients and accepting facilities. Telestroke (TS) improves acute stroke care access, but data lack on inpatient teleneurology follow-up (TNF) care. We hypothesized that IS patients evaluated in the ED via TS, then admitted and managed by TNF, have similar outcomes to those seen by in-person neurology follow-up (IPF) after admission. Methods: In our spoke EDs, 4069 IS patients were seen via TS (9/2015-12/2018). Figure 1 demonstrates hospital stroke designations and patient triage patterns. Transfer was at ED discretion. We compared baseline demographics, clinical characteristics, and hospital outcomes in patients with TNF vs IPF. Results: There were 447 (23%) patients with TNF and 1459 (77%) IPF. Both groups presented with similar stroke severity (Table 1). In multivariate analysis, there were no significant differences in discharge disposition, stroke readmission rates, or 90-day mRS; length of stay was shorter with TNF. tPA-only patients showed no differences in outcomes and similar complication rates. TNF patients less likely received tPA or endovascular therapy. TNF resulted in a 3% transfer rate for higher level of care. There remained no difference in outcomes in a sub-analysis without CSCs. A higher proportion of non-Hispanic Black patients and lower proportion of Hispanic patients in the TNF group were possibly due to spoke demographics. Conclusion: TNF resulted in comparable outcomes to IPF and few transfers after admission. For select IS patients, TNF provides an alternative to transfer for hospitals lacking neurology coverage.

Introduction: Recent studies support tPA for acute ischemic stroke (AIS) patients presenting beyond 4.5 hours from last known well (LKW), if established infarct is not evident on advanced imaging. Many community hospitals, where AIS patients may be managed via telestroke (TS), lack advanced imaging capability and hesitate to administer off-label tPA. In our TS network, physicians adhere to an extended window tPA (EW) protocol also used in the hub emergency room; eligibility includes NIHSS≤25, Methods: We identified 1,150 AIS patients who received tPA via TS (9/2015-12/2018). We compared baseline characteristics between patients who received EW (arrival >4.5 hrs) and those who received standard window tPA (SW, arrival ≤4.5 hrs). We explored clinical outcomes and describe incidence of adverse effects from tPA. Results: Forty patients received EW, with median ASPECTS of 9 (Q1-Q3: 9-10). Median LKW to arrival time was 491 mins with EW and 66 mins with SW (p Conclusions: Our data suggest that EW is safe via TS for select patients with favorable CT, in settings that may lack advanced imaging capability. A specified mismatch between NIHSS and acute ischemia on plain CT is not part of our EW protocol, however EW is more likely given for severe stroke in our TS network. Small sample size warrants further study on clinical outcomes.

Background and Purpose— There is uncertainty among many emergency medicine physicians about the decision to give intravenous tPA (tissue-type plasminogen activator), which limits its use. A checklist approach has been suggested as a solution. We compared agreement on tPA treatment in suspected acute ischemic stroke patients between emergency medicine residents (EMRs) using a checklist and vascular neurology fellows (VNFs). Methods— Every suspected acute stroke patient brought to our comprehensive stroke center emergency room within 4.5 hours from symptom onset was prospectively evaluated simultaneously and independently by VNFs and EMRs. The latter used a tPA screening checklist, which included guideline exclusion criteria to help with their treatment decision. Agreement was determined using kappa (k) statistics. Results— Over 6 months, 60 patients were enrolled; 10% large vessel atherosclerosis, 18% cardioembolism, 12% small vessel, 12% cryptogenic, and 47% mimic. Forty-two percent were deemed tPA eligible by the EMR, 30% by the VNF, and 37% by the vascular neurology faculty. There were no complications in any tPA-treated patients. Agreement was substantial between EMR and VNF (κ=0.68 [95% CI, 0.49–0.87]) and between EMR and vascular neurology faculty (κ=0.69 [95% CI, 0.50–0.87]). Stroke mimics were the main cause of disagreement between EMR and VNF (κ=0.24 [95% CI, −0.15 to 0.63]) and between EMR and vascular neurology faculty (κ=0.35 [95% CI, −0.08 to 0.78]). Conclusions— Our data suggest that with the aid of a checklist, EMRs can accurately treat stroke patients with tPA. Areas for improvement include recognition of stroke mimics. Further studies are warranted to evaluate checklist-enhanced tPA treatment to allay emergency medicine physician uncertainty and expand the use of tPA.

Background: There is uncertainty among many emergency medicine physicians about the decision to give intravenous tissue-type plasminogen activator (tPA) in suspected acute ischemic stroke patients, which limits its use. A checklist approach has been suggested as a solution. Objective: To compare agreement on tPA treatment in suspected acute ischemic stroke patients between vascular neurology and emergency medicine physicians using a checklist. Methods: Every suspected acute stroke patient brought to our comprehensive stroke center emergency room within 4.5 hours from symptom onset was prospectively evaluated simultaneously and independently by vascular neurology fellows (VNF) and emergency medicine residents (EMR). The latter used a tPA screening checklist, which included guideline exclusion criteria to help with their treatment decision. Agreement between the EMR and the VNF and a senior VN faculty was determined using Cohen’s kappa (κ) statistics. Results: Over 5 months, 60 patients were enrolled, age 63±16, 50% female, NIHSS median 6 (IQR: 1,14), premorbid mRS > 2 30%. Eventual etiology was: 10% large vessel atherosclerosis, 18% cardioembolism, 12% small vessel, 12% cryptogenic, and 48% mimic. 25 (42%) were deemed tPA eligible by the EMR, 18 (30%) by the VNF, and 22 (37%) by the VN faculty. Agreement was substantial between EMR and VNF (κ=0.68, 95% CI 0.49 to 0.87) and between EMR and VN faculty (κ=0.69, 95% CI 0.50 to 0.87]). Age, NIHSS, premorbid mRS, gender and race had no effect on agreement. There were no complications in any tPA treated patients. Stroke mimics were the main cause of disagreement between EMR and VNF (κ=0.24, 95% CI -0.15 to 0.63) and between EMR and VN faculty (κ=0.35, 95% CI -0.08 to 0.78). Conclusions: Our data suggest that with the aid of a checklist, emergency medicine physicians can reliably treat acute stroke patients with tPA. Areas for improvement include recognition of stroke mimics. Further studies are warranted to evaluate checklist enhanced tPA treatment in order to allay emergency medicine physician uncertainty and expand the use of tPA.

BackgroundUnprecedented workflow shifts during the coronavirus disease 2019 (COVID-19) pandemic have contributed to delays in acute care delivery, but whether it adversely affected endovascular thrombectomy metrics in acute large vessel occlusion (LVO) is unknown.MethodsWe performed a retrospective review of observational data from 14 comprehensive stroke centers in nine US states with acute LVO. EVT metrics were compared between March to July 2019 against March to July 2020 (primary analysis), and between state-specific pre-peak and peak COVID-19 months (secondary analysis), with multivariable adjustment.ResultsOf the 1364 patients included in the primary analysis (51% female, median NIHSS 14 [IQR 7–21], and 74% of whom underwent EVT), there was no difference in the primary outcome of door-to-puncture (DTP) time between the 2019 control period and the COVID-19 period (median 71 vs 67 min, P=0.10). After adjustment for variables associated with faster DTP, and clustering by site, there remained a trend toward shorter DTP during the pandemic (βadj=-73.2, 95% CI −153.8–7.4, Pp=0.07). There was no difference in DTP times according to local COVID-19 peaks vs pre-peak months in unadjusted or adjusted multivariable regression (βadj=-3.85, 95% CI −36.9–29.2, P=0.80). In this final multivariable model (secondary analysis), faster DTP times were significantly associated with transfer from an outside institution (βadj=-46.44, 95% CI −62.8 to – -30.0, Padj=-2.15, 95% CI −4.2to – -0.1, P=0.05).ConclusionsIn this multi-center study, there was no delay in EVT among patients treated for intracranial occlusion during the COVID-19 era compared with the pre-COVID era.

Background: Animal models have demonstrated the deleterious contribution that immunocytes from the spleen exert on secondary brain injury after stroke. While previous work has demonstrated that there is splenic contraction (SC) in patients with acute ischemic stroke (AIS) and intracranial hemorrhage (ICH), no clinical studies have connected the systemic inflammatory response syndrome (SIRS) with SC. We aim to associate SIRS and its individual components with SC in acute stroke Methods: This is a retrospective analysis of a previous prospective observational study where daily spleen sizes were evaluated in 178 acute stroke patients in a tertiary care center from 2010-2013. Spleen contraction was defined compared to previously established normograms of healthy volunteers from the same study. SIRS was defined as the presence of 2 or more of the following: body temperature 38C, heart rate >90 beats, respiratory rate >20, and serum white blood cell count >12,000 or Results: 91 patients had verified AIS without concurrent infection at admission and 70 of these patients remained inpatient at 72 hrs. SIRS was not associated with admission SC at 24hr and 72 hrs. Patients with SIRS at 24 and 72 hrs were more likely to have higher admission NIHSS. SIRS was associated with higher discharge mRS (OR 4.24, 95% CI 1.64-10.9, p=0.0028) and PEG placement (OR 3.70, 95% CI 0.95-15.11, p=0.05). 16 patients (22.9%) developed SIRS by 72hrs, only 5 of whom had SC initially. 28 patients (47%) had SIRS on admission that persisted, 12 of whom had SC. SC was not associated with SIRS at 72 hrs (OR 1.05, 95% CI 0.35-2.79, p = 0.92). 14 patients (15%) developed infections while hospitalized, of which 85% had SIRS on admission. Conclusion: Based on our initial evaluation, SC detected within 24 hrs of stroke onset is not associated with SIRS suggesting that the relationship between the two may be more complicated in humans. Consistent with prior studies, however, SIRS is associated with worse outcome. Further studies and additional time points are necessary to further clarify the role of the spleen in the development of SIRS in stroke patients.

In 2013, Dall et al.1 projected that by 2025, the societal need for neurologists will exceed availability by 19%. This number failed to account for the disproportionate number of neurologists practicing in urban and academic centers, likely underestimating the gap in rural populations. In a recent effort to improve access to neurologic services in these areas, telestroke and teleneurology networks have being championed as the solution. With the emergence of these networks come unique challenges and opportunities in the distribution and breadth of neurologic care that fellows and residents will need to understand to optimally incorporate this tool into their future practices.

Objective: Recent evidence suggests that a potential harmful relationship exists between cannabis use and ischemic stroke. The purpose of this study was to determine the implications of cannabis use in intracerebral hemorrhage (ICH) patients. Methods: An analysis of an international, multicenter, observational database of consecutive patients with spontaneous ICH was conducted. We extracted the following characteristics on presentation: demographics, risk factors, antiplatelet or anticoagulant use, Glasgow Coma Scale, ICH score, neuroimaging parameters, and urine toxicology screen (UTS) results. Modified Rankin Scale (mRS) score was utilized for determination of outcome at discharge. Adjusted logistic ordinal regression was used as shift analysis to assess the impact of cannabis use on mRS score at discharge. The adjusted common OR measured the likelihood that cannabis use would lead to lower mRS scores. Results: Within a cohort of 725 spontaneous ICH patients, UTS was positive for cannabinoids in 8.6%. Cannabinoids-positive (CB+) patients were more frequently Caucasian (p < 0.001), younger (p < 0.001), and had lower median ICH scores on admission (p = 0.017) than those who were cannabinoids-negative. CB+ patients also showed a shift toward better outcome in the distribution of mRS categories, with an adjusted common OR of 0.544 (95% CI 0.330-0.895, p = 0.017). Conclusion: In this multinational cohort, cannabis use was discovered in nearly 10% of patients with spontaneous ICH. Although there was no relationship between cannabis use and specific ICH characteristics, CB+ patients had milder ICH presentation and less disability at discharge.

Objective Anorexia nervosa is associated with a high prevalence of psychiatric comorbidities, including anxiety and depression, and with endocrine dysfunction, including relative androgen deficiency compared with healthy young women. Because androgens are known to affect mood and behavior, we hypothesized that low endogenous androgen production in anorexia nervosa would predict anxiety and depression severity. Method Serum androgen levels and severity of depression (Hamilton Rating Scale for Depression) and anxiety (Hamilton Rating Scale for Anxiety) were measured in 43 community-dwelling women with DSM-IV-defined anorexia nervosa from May 2004 to July 2006. Results Strong inverse associations were observed between both total and free testosterone and anxiety and depression severity, independent of weight. Free testosterone was also inversely associated with 4 eating-disordered thinking and behavior subscales of the Eating Disorder Inventory 2 (EDI-2). Mean free testosterone blood levels were lower in women with clinically significant anxiety and in women with clinically significant depression, compared with those without. In stepwise regression models, free testosterone was an important predictor of anxiety and depression severity. EDI-2 ineffectiveness, perfectionism, interpersonal distress, and social insecurity scores were also inversely associated with androgen levels, independent of weight. Conclusions Our data suggest that low androgen levels may contribute to anxiety, depression, and eating-disordered thinking and behavior in women with anorexia nervosa and form the basis for future studies to investigate the effectiveness of androgen replacement therapy. Clinical trials registration ClinicalTrials.gov identifier NCT00089843.

The risk of cerebrovascular disease is increased among rheumatoid arthritis (RA) patients and remains an underserved area of medical need. Only a minor proportion of RA patients achieve suitable stroke prevention. Classical cardiovascular risk factors appear to be under-diagnosed and undertreated among patients with RA. Reducing the inflammatory burden is also necessary to lower the cardiovascular risk. An adequate control of disease activity and cerebrovascular risk assessment using national guidelines should be recommended for all patients with RA. For patients with a documented history of cerebrovascular or cardiovascular risk factors, smoking cessation and corticosteroids and non-steroidal anti-inflammatory drugs at the lowest dose possible are crucial. Risk score models should be adapted for patients with RA by introducing a 1.5 multiplication factor, and their results interpreted to appropriately direct clinical care. Statins, angiotensin-converting enzyme inhibitors, and angiotensin-II receptor blockers are preferred treatment options. Biologic and non-biologic disease-modifying anti-rheumatic drugs should be initiated early to mitigate the necessity of symptom control drugs and to achieve early alleviation of the inflammatory state. Early control can improve vascular compliance, decrease atherosclerosis, improve overall lipid and metabolic profiles, and reduce the incidence of heart disease that may lead to atrial fibrillation. In patients with significant cervical spine involvement, early intervention and improved disease control are necessary and may prevent further mechanical vascular injury.

Large hemispheric infarction is a devastating disease that continues to be associated with significant mortality and morbidity. Most often these patients are admitted to the ICU requiring significant physician and nursing resources. This review will address some of the ICU management issues and review the evidence supporting medical and surgical management of malignant cerebral edema.The most recent changes in management of large hemispheric infarct include the American Heart Association and Neurocritical Care Guidelines. These guidelines address airway management and mechanical ventilation, blood pressure control, fluid management, and glucose and temperature control. In addition, they addressed the indication for surgical management of cerebral edema. We review the recent guidelines updates and trials of surgical management of large hemispheric infarcts.Large hemispheric infarcts continue to have significant morbidity and mortality. Recent guidelines have provided an excellent framework to help intensivists manage these complicated patients. Recent surgical data continue to support early hemicraniectomy even in elderly patients.

Stress and glucocorticoids exacerbate pain via undefined mechanisms. Macrophage migration inhibitory factor (MIF) is a constitutively expressed protein that is secreted to maintain immune function when glucocorticoids are elevated by trauma or stress. Here we show that MIF is essential for the development of neuropathic and inflammatory pain, and for stress-induced enhancement of neuropathic pain. Mif null mutant mice fail to develop pain-like behaviors in response to inflammatory stimuli or nerve injury. Pharmacological inhibition of MIF attenuates pain-like behaviors caused by nerve injury and prevents sensitization of these behaviors by stress. Conversely, injection of recombinant MIF into naive mice produces dose-dependent mechanical sensitivity that is exacerbated by stress. MIF elicits pro-inflammatory signaling in microglia and activates sensory neurons, mechanisms that underlie pain. These data implicate MIF as a key regulator of pain and provide a mechanism whereby stressors exacerbate pain. MIF inhibitors warrant clinical investigation for the treatment of chronic pain.