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Background: The Florida Stroke Act, signed into law in 2004, set criteria for Comprehensive Stroke Centers (CSC). For a set time period, Florida hospitals were permitted to either receive national certification (NC) or could self-attest (SA) as fulfilling CSC criteria. The aim of this project was to evaluate the quality of ischemic stroke care in NC versus SA stroke centers in Florida, using well-known, guideline-driven ischemic stroke outcome metrics. Methods: A total of 37 CSCs (74% of Florida CSCs) in the Florida Stroke Registry from January 2013 through December 2018 were analyzed, including 19 SA CSCs and 18 NC (13 CSCs and 5 Thrombectomy-Capable Stroke Center). Hospital- and patient-level characteristics and stroke metrics were evaluated, adjusting for demographics, medical comorbidities, and stroke severity. Results: A total of 78 424 acute ischemic stroke cases, 36 089 from SA CSCs and 42 335 from NC CSC/Thrombectomy-Capable Stroke Centers were analyzed. NC centers had older patients (73 [61–83] versus 71 [60–81]; P P P P P P P P =0.001) and more likely to be treated with intravenous tissue-type plasminogen activator within 45 minutes (adjusted odds ratio, 1.61 [95% CI, 1.04–2.50]; P =0.04) compared with SA CSCs. Conclusions: Among Florida-Stroke Registry CSCs, acute ischemic stroke performance and treatment measures at NC centers are superior to SA CSCs. These findings have implications for stroke systems of care in Florida and support legislation updates requiring NC and removal of SA claims.

Background: Although carotid artery web (CaW) was initially described in 1973 as a potential etiology of ischemic stroke, it still remains underrecognized. Because CaW is a membrane affixed perpendicularly from the carotid wall that projects out into the lumen above the bifurcation, it typically is not stenotic, and hence, utilizing only 1 vessel imaging modality during conventional stroke workup may instead lead to a diagnosis of ESUS: embolic stroke of undetermined source. The term ESUS was created in 2014 by researchers to define a subset of cryptogenic, nonlacunar (embolic-appearing) strokes without clear cardiac or vascular cause. Purpose: In this review, we describe how, after multiple evaluations of vessels, CaW was diagnosed in relatively young patients (age 39-47 years old, without significant vascular risk factors) in whom otherwise were considered embolic stroke of undetermined source. This observation dovetails with the accompanying Neurohospitalist article entitled, “Delayed Thrombus Formation on Carotid Web and Its Medical and Endovascular Management for Secondary Stroke Prevention.” Research Design: Not applicable. Case review. Results/Conclusion: This report demonstrates the futility of antiplatelet therapy for a young patient with CaW-related stroke. Based on these collective experiences and review of the literature, we postulate that: (1) multiple vascular imaging modalities during stroke workup may result in a CaW diagnosis instead of ESUS; (2) young stroke patients without traditional vascular risk factors are candidates for this “web browsing” of extended imaging of vessels; and (3) carotid artery stenting (CAS) or carotid endarterectomy (CEA) may be preferred as first-line over medical therapy alone (ie, antiplatelet or anticoagulation) because CEA/CAS addresses the stroke etiology, CaW, definitively.

Introduction The risk of hemorrhagic transformation (HT) in the early phase of acute ischemic stroke (AIS) remains unknown, leading to potential unnecessary delays in initiation of anticoagulation for secondary stroke prevention. We sought to assess the rate of HT associated withdirect oral anticoagulant (DOAC) initiation within and beyond 48 hours after AIS, using a pooled analysis of available published data. Methods A pooled analysis of 6 studies (4 prospective observational blinded outcome studies and2 randomized trials) of DOAC initiation within 14 days of AIS or transient ischemic attack (TIA) was conducted. The primary endpoint was incident radiographic HT on follow‐up imaging. Secondary endpoints included symptomatic HT, new parenchymal hemorrhage, recurrent ischemic events, extracranial hemorrhage, mortality within the study period, and follow‐up modified Rankin Scale score.The results were reported as odds ratio (OR) andhazard ratio (HR)with 95% confidence interval (CI). Results We evaluated 509 patients; median infarct volume was1.5 (0.1‐7.8) ml, andmedian National Institutes of Health Stroke Scale was2 (0‐3).Incident radiographic HT was seen on follow‐up scan in 34 (6.8%) patients.DOAC initiation within 48 hours from index event was not associated with incident HT (adjusted OR 0.67, [0.30 – 1.50]P = 0.32).No patients developed symptomatic HT.Conversely, 31 (6.1%) patients developedrecurrent ischemic events, 64% of which occurred within 14 days.Initiating a DOAC within 48 hours of onset was associated with a trend towards lower rates of recurrent ischemic events, but this was not statistically significant (HR 0.42, [0.17 – 1.008]P = 0.052). In contrast to HT,recurrent ischemic events were associated with poor functional outcomes (OR = 6.8, [2.84 – 16.24], p< 0.001). Conclusions Initiation of DOAC within 48 hours after stroke was not associated with decreased risk of recurrent ischemic events, or increasedincident risk of HT. Both recurrent ischemic events and incident HT occurred at similar rates.Unlike HT, however, recurrent ischemic events were associated with poor outcomes.

BackgroundGuideline based hypertension management is integral to the prevention of stroke. We examine trends in antihypertensive medications prescribed after stroke and assess how well a prescribers’ blood pressure medication choice adheres to clinical practice guidelines (Prescribers’-Choice Adherence).MethodsThe Florida Stroke registry (FSR) utilizes statewide data prospectively collected for all acute stroke admissions. Based on established guidelines we defined optimal Prescribers’-Choice Adherence using the following hierarchy of rules: 1) use of an angiotensin inhibitor (ACEI) or angiotensin receptor blocker (ARB) as first-line antihypertensive among diabetics; 2) use of thiazide-type diuretics or calcium channel blockers (CCB) among African-American patients; 3) use of beta-adrenergic blockers (BB) among patients with compelling cardiac indication (CCI) 4) use of thiazide, ACEI/ARB or CCB class as first-line in all others; 5) BB should be avoided as first line unless CCI.RESULTSA total of 372,254 cases from January 2010 to March 2020 are in FSR with a diagnosis of acute ischemic, hemorrhagic stroke, transient ischemic attack or subarachnoid hemorrhage; 265,409 with complete data were included in the final analysis. Mean age 70 +/-14 years, 50% female, index stroke subtype of 74% acute ischemic stroke and 11% intracerebral hemorrhage. Prescribers’-Choice Adherence to each specific rule ranged from 48-74% which is below quality standards of 85%. There were race-ethnic disparities with only 49% Prescribers choice Adherence for African Americans patients.ConclusionThis large dataset demonstrates consistently low rates of Prescribers’-Choice Adherence over 10 years. There is an opportunity for quality improvement in hypertensive management after stroke.

Introduction: Imprecise timing of symptom onset (SO) in patients with acute ischemic stroke (AIS) may impact eligibility for reperfusion therapy. Unreliable “last-known-well” (LKW) estimates may reduce the use of thrombolytic or endovascular treatments. A blood biomarker that serves as a “stroke clock” could minimize uncertainty and augment treatment rates. Methods: The single-center VuEssence Stroke Trial (VEST) evaluated gene expression biomarkers in adult ED patients with suspected AIS, a LKW time < 24hrs, and timing of SO accurate within a 0-3 hour time frame. At ED presentation and before reperfusion treatment, whole blood was collected in PAXgene RNA tubes for RNA-sequencing and gene expression analysis. Researchers blinded to molecular results adjudicated final diagnosis (AIS vs stroke mimic) and estimated time of SO based on times of witnessed onset (WO), LKW, and symptom discovery (SD). The confirmed AIS subgroup with WO timing, or ≤60 minutes between LKW and SD, was analyzed. Results: Of AIS patients, 56 met criteria (52% men, mean age 71.6). The average time from SO was 148 minutes (range 48-490). After RNA-sequencing, linear regression showed 684 genes with a significant linear time-related expression change in reference to time from SO (0.25 were used to generate multiple classifiers of up to 12 genes that identified AIS table ). Conclusion: Using a biological “stroke clock” biomarker instead of SO timing may streamline evaluations of suspected AIS, augment reperfusion therapy rates, and improve outcomes. VEST identified time-related gene expression changes that may accurately classify AIS

Introduction Breakthrough acute ischemic stroke (AIS) in patients with known, nonvalvular Atrial Fibrillation (AF), on Direct Oral Anticoagulants (DOAC), is an ongoing clinical conundrum. Switching anticoagulants was shown to be ineffective in preventing recurrent AIS. Systematic, patient-level chart review of so-called “DOAC failures” may offer insight into this phenomenon. Methods We conducted an IRB-approved, 6-year, retrospective study of AIS admissions, already prescribed DOAC for known AF. We sought plausible, alternative reasons for the AIS using a novel classification schema, CLAMP: C for Compliance concerns, L for Lacunes (small-vessel disease), A for Arteriopathy (atherosclerosis, web, or vasculitis), M for Malignancy, and P for Patent Foramen Ovale (PFO). These categories were labeled as DOAC “Pseudo-failures.” Conversely, absence of CLAMP variables were labeled as DOAC “Crypto-failures” conceivably from AF itself (“atriopathy”) or pharmacokinetic/pharmacogenomic dysfunction (ie, altered DOAC absorption, clearance, metabolism, or genetic polymorphisms). Forward logistic regression analysis was performed on prespecified DOAC subgroups. Results Of 4890 AIS admissions, 606 had AF, and 87 were previously prescribed DOAC (14.4% overall DOAC failure rate, 2.4% annualized over 6 years). Pseudo-failures comprised 77%: Compliance concerns (48.9%), Lacunes (5.7%), Arteriopathy (17.0%), Malignancy (26.1%), and PFO (2.3%). Crypto-failures comprised 23%, had lower CHADSVASc scores (AOR = .65, P = .013), and occurred more with rivaroxaban (41%) than apixaban (16%) or dabigatran (5.6%). Conclusion In AIS patients with known AF, DOAC Pseudo-failures, with identified alternate etiologies, are 3 times more likely than DOAC Crypto-failures. The CLAMP schema represents a novel approach to diagnostic classification and therapeutic adjustments in patients already prescribed DOAC for AF.

Introduction: Precise risk of hemorrhagic transformation (HT) in acute ischemic stroke (AIS) remains unknown, leading to delays in anticoagulation initiation for secondary stroke prevention. We sought to assess the rate of HT associated with direct oral anticoagulant (DOAC) initiation within and beyond 48 h post-AIS. Methods: A pooled analysis of DOAC initiation within 14 days of AIS or transient ischemic attack (TIA) was conducted with six studies (four prospective open label treatment, blinded outcome studies and two randomized trials; NCT02295826 and NCT02283294). The primary endpoint was incident radiographic HT on follow-up imaging (days 7–30). Secondary endpoints included symptomatic HT, new parenchymal hemorrhage, recurrent ischemic events, extracranial hemorrhage, study period mortality, and follow-up modified Rankin Scale score. The results were reported as odds ratio (OR) or hazard ratio (HR) with 95% confidence interval (CI). Results: We evaluated 509 patients; median infarct volume was 1.5 (0.1–7.8) ml, and median National Institutes of Health Stroke Scale was 2 (0–3). Incident radiographic HT was seen on follow-up scan in 34 (6.8%) patients. DOAC initiation within 48 h from index event was not associated with incident HT (adjusted OR 0.67, [0.30–1.50] P = 0.32). No patients developed symptomatic HT. Conversely, 31 (6.1%) patients developed recurrent ischemic events, 64% of which occurred within 14 days. Initiating a DOAC within 48 h of onset was associated with similar recurrent ischemic event rates compared with those in which treatment was delayed (HR: 0.42, [0.17–1.008] P = 0.052). In contrast to HT, recurrent ischemic events were associated with poor functional outcomes (OR = 6.8, [2.84–16.24], p Conclusions: In this pooled analysis, initiation of DOAC within 48 h post-stroke was not associated with increased incident risk of HT, and none developed symptomatic HT. The analysis was underpowered to determine the effect of early DOAC use upon recurrent ischemic events.

Background: Access to endovascular therapy (EVT) should be equitable to all eligible ischemic stroke patients presenting within the treatment time window. In the Florida Stroke Registry (FSR) we sought to determine sex, race/ethnic, hospital and regional disparities in the delivery of EVT. Methods: From January 2010 to January 2020, a total of 99,088 ischemic stroke cases within 24 hours of symptom onset were enrolled. Multivariable logistic regression with generalized estimating equations evaluated independent predictors of EVT utilization. Results: A total of 7,812 patients received EVT (51.2% female, mean age 71.3 ± SD 14.6 years, 61.4% white, 17.4% black, 21.2% Hispanic). Compared to those not treated, EVT treated patients were more likely Hispanic (21.2% vs. 14.6%), arrived earlier to the hospital (median 120 min (IQR 292) vs. 170 min (IQR 446)), via EMS (94% vs. 66%), with more severe strokes (median NIHSS 15 (IQR11) vs. 5 (IQR 9)), to large hospitals (≥ 680 beds) (73.4% vs. 47.7%), in South Florida (50.8% vs. 38.2%). In multivariable analysis, female sex (OR 1.05, 95% CI 1-1.11), atrial fibrillation (OR 1.57, 95% CI 1.45-1.7), higher NIHSS (> 6) (OR 6.19, 95% CI 5.11-7.51) and presenting to a high-volume hospital (OR 3.47, 95% CI 2.25-5.36) positively predicted EVT utilization, whereas older age (>80 years) (OR 0.88, 95% CI 0.80-0.96), and black race (vs. white OR 0.87, 95% CI 0.76-1), were independently associated with lower use of EVT. Conclusions: In this large state-wide registry study, we found significant race-ethic and geographical disparities in delivery of EVT. Systems of care should address disparities in stroke treatment to improve access to EVT for all eligible stroke patients.

Introduction: Prolonged cardiac monitoring after cryptogenic stroke reveals a cardiac cause in up to 30% of patients; however, practice patterns for monitoring vary widely. We sought to evaluate overall and race/ethnic trends in the rate of ECG monitoring and types of cardiac monitoring performed after ischemic stroke and transient ischemic attack (TIA) across a network of hospitals in Florida and Puerto Rico(PR). Methods: We identified 46,878 ischemic stroke and TIA cases with data on ECG monitoring in the Florida Stroke Registry from 2016-18. Univariate analysis was performed to determine the overall rate of ECG monitoring and the characteristics of patients who received cardiac surface monitoring ≤7days and >7days, and implantable cardiac monitoring. Multivariate logistic regression was performed to identify factors associated with the types of monitoring. Results: Overall, 39,333 (84%) patients admitted for stroke/TIA received ECG monitoring during hospital admission (mean age 71±14 years; 49% female; 63% white, 18% black, 15% FL-Hispanic, 4% PR-Hispanic). Compared to patients who received ECG monitoring, patients who did not were more likely to be younger (mean age 70±15 years), PR-Hispanic (24% vs 4.3%), and have TIA (13% vs 8%), Medicare (42% vs 35%), large vessel disease (14% vs 9%) and greater admission NIHSS (median score 5 vs 4). After adjustment, smokers and patients >80years were less likely to receive ECG monitoring overall (OR 0.95, 95% CI 0.9-0.99 for both). Black race was associated with receiving extended surface monitoring >7 days (OR 1.15, 95%CI 1.04-1.26), but negatively associated with implantable cardiac monitoring (OR 0.81, 95%CI 0.68-0.96). Patients with moderate/severe stroke had higher odds of extended surface monitoring >7days (OR 2.29, 95%CI 1.89-2.77), yet lower odds of implantable cardiac monitoring (OR 0.80, 95%CI 0.71-0.89). Conclusion: The majority of patients received ECG monitoring during hospital admission for stroke/TIA; however, significant differences were found with respect to age, race/ethnicity and stroke severity across the various types and duration of cardiac monitoring. Further research is needed to understand and address the underlying drivers of these differences.

Background and Purpose: It is unknown when to start anticoagulation after acute ischemic stroke (AIS) from atrial fibrillation (AF). Early anticoagulation may prevent recurrent infarctions but may provoke hemorrhagic transformation as AF strokes are typically larger and hemorrhagic transformation-prone. Later anticoagulation may prevent hemorrhagic transformation but increases risk of secondary stroke in this time frame. Our aim was to compare early anticoagulation with apixaban in AF patients with stroke or transient ischemic attack (TIA) versus warfarin administration at later intervals. Methods: AREST (Apixaban for Early Prevention of Recurrent Embolic Stroke and Hemorrhagic Transformation) was an open-label, randomized controlled trial comparing the safety of early use of apixaban at day 0 to 3 for TIA, day 3 to 5 for small-sized AIS ( Results: Although AREST ended prematurely after a national guideline focused update recommended direct oral anticoagulants over warfarin for AF, it revealed that apixaban had statistically similar yet generally numerically lower rates of recurrent strokes/TIA (14.6% versus 19.2%, P =0.78), death (4.9% versus 8.5%, P =0.68), fatal strokes (2.4% versus 8.5%, P =0.37), symptomatic hemorrhages (0% versus 2.1%), and the primary composite outcome of fatal stroke, recurrent ischemic stroke, or TIA (17.1% versus 25.5%, P =0.44). One symptomatic intracerebral hemorrhage occurred on warfarin, none on apixaban. Five asymptomatic hemorrhagic transformation occurred in each arm. Conclusions: Early initiation of anticoagulation after TIA, small-, or medium-sized AIS from AF does not appear to compromise patient safety. Potential efficacy of early initiation of anticoagulation remains to be determined from larger pivotal trials. Registration: URL: https://www.clinicaltrials.gov/ ; Unique identifier: NCT02283294.

Background and Purpose: Initial reports suggest a significant risk of thrombotic events, including stroke, in patients hospitalized with coronavirus disease 2019 (COVID-19). However, there is little systematic data on stroke incidence and mechanisms, particularly in racially diverse populations in the United States. Methods: We performed a retrospective, observational study of stroke incidence and mechanisms in all patients with COVID-19 hospitalized from March 15 to May 3, 2020, at 3 Philadelphia hospitals. Results: We identified 844 hospitalized patients with COVID-19 (mean age 59 years, 52% female, 68% Black); 20 (2.4%) had confirmed ischemic stroke; and 8 (0.9%) had intracranial hemorrhage. Of the ischemic stroke patients, mean age was 64 years, with only one patient (5%) under age 50, and 80% were Black. Conventional vascular risk factors were common, with 95% of patients having a history of hypertension and 60% a history of diabetes mellitus. Median time from onset of COVID symptoms to stroke diagnosis was 21 days. Stroke mechanism was cardioembolism in 40%, small vessel disease in 5%, other determined mechanism in 20%, and cryptogenic in 35%. Of the 11 patients with complete vascular imaging, 3 (27%) had large vessel occlusion. Newly positive antiphospholipid antibodies were present in >75% of tested patients. Of the patients with intracranial hemorrhage, 5/8 (63%) were lobar intraparenchymal hemorrhages, and 3/8 (38%) were subarachnoid hemorrhage; 4/8 (50%) were on extracorporeal membrane oxygenation. Conclusions: We found a low risk of acute cerebrovascular events in patients hospitalized with COVID-19. Most patients with ischemic stroke had conventional vascular risk factors, and traditional stroke mechanisms were common.

BACKGROUND AND PURPOSE: Atrial Fibrillation (AF) is the most common cardiac cause of ischemic stroke. However, the relation between AF and stroke care outcomes in diverse populations is understudied. We aimed to evaluate sex and race-ethnic disparities associated with AF in hospital stroke outcomes utilizing data from the FLorida PuErto Rico Atrial Fibrillation (FLiPER–AF) Stroke Study. METHODS: The study included 104,308 ischemic stroke cases with available information on AF status enrolled in a state-wide stroke registry from 2010 to 2016. Multivariable logistic regression models were performed to evaluate the association between AF and stroke outcomes and the modification effects on the associations by sex and by race-ethnicity, adjusted for socio-demographic status, vascular risk factors and stroke severity. RESULTS: AF was present in 23% of ischemic stroke cases. AF was associated with worse disability at discharge (OR=1.11, 95% CI, 1.04–1.18), less discharge to home (OR=0.89, 0.85–0.92), and longer length of hospital stay (LOS>6 days, OR=1.53, 1.46–1.60). Interaction analyses showed that the association between AF and less discharge to home was stronger in women than men (p for interaction

Background and Purpose— The RE-SPECT ESUS trial (Randomized, Double-Blind, Evaluation in Secondary Stroke Prevention Comparing the Efficacy and Safety of the Oral Thrombin Inhibitor Dabigatran Etexilate Versus Acetylsalicylic Acid in Patients With Embolic Stroke of Undetermined Source) tested the hypothesis that dabigatran would be superior to aspirin for the prevention of recurrent stroke in patients with embolic stroke of undetermined source. This exploratory subgroup analysis investigates the impact of age, renal function (both predefined), and dabigatran dose (post hoc) on the rates of recurrent stroke and major bleeding. Methods— RE-SPECT ESUS was a multicenter, randomized, double-blind trial of dabigatran 150 or 110 mg (for patients aged ≥75 years and/or with creatinine clearance 30 to Results— The trial, which enrolled 5390 patients from December 2014 to January 2018, did not demonstrate superiority of dabigatran versus aspirin for prevention of recurrent stroke in patients with embolic stroke of undetermined source. However, among the population qualifying for the lower dabigatran dose, the rate of recurrent stroke was reduced with dabigatran versus aspirin (7.4% versus 13.0%; hazard ratio, 0.57 [95% CI, 0.39–0.82]; interaction P =0.01). This was driven mainly by the subgroup aged ≥75 years (7.8% versus 12.4%; hazard ratio, 0.63 [95% CI, 0.43–0.94]; interaction P =0.10). Stroke rates tended to be lower with dabigatran versus aspirin with declining renal function. Risks for major bleeding were similar between treatments, irrespective of renal function, but with a trend for lower bleeding rates with dabigatran versus aspirin in older patients. Conclusions— In subgroup analyses of RE-SPECT ESUS, dabigatran reduced the rate of recurrent stroke compared with aspirin in patients qualifying for the lower dose of dabigatran. These results are hypothesis-generating. Aspirin remains the standard antithrombotic treatment for patients with embolic stroke of undetermined source. Registration— URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02239120.

Background: Oral anticoagulants (OACs) for stroke prevention in atrial fibrillation (AF) are largely underutilized. We identified pre-admission OAC utilization patterns and factors predictive of OAC non-use in patients hospitalized for AF-related stroke. Methods: We included 22,220 patients with ischemic stroke due to previously diagnosed AF enrolled in the Florida Stroke Registry from 2010-2017. A multivariable-adjusted logistic regression model was used to identify factors associated with pre-stroke OAC use for patients with AF-related stroke. Results: A total of 16,246 (73%) patients with AF-related stroke were not on OAC pre-stroke. Compared to patients on OAC, non-OAC patients were more likely to be ≥80 years old, have Medicaid/no insurance, lower CHA 2 DS 2 -VASc scores and greater stroke severity at presentation. After adjustment for age, sex, race-ethnicity, insurance status and vascular risk factors, baseline OAC non-use was higher for patients with Medicaid/no insurance (vs. private insurance, (OR 1.34 [95% CI 1.08-1.67]), smokers (OR 1.29 [1.09-1.52] and patients with NIHSS ≥6 (vs. NIHSS≤5, OR 1.18 [1.11-1.26]). A trend towards greater odds of OAC non-use was seen in women (vs. men, OR 1.07 [0.99-1.14, P=0.07]). Conclusion: The majority of AF-related stroke patients with known AF were not anticoagulated prior to hospitalization for stroke in our study. Insurance status and smoking status had the greatest influence on pre-stroke OAC use. Anticoagulated patients had lower stroke severity on admission. Further efforts are needed to increase OAC use to reduce the burden of stroke for patients with AF, especially for vulnerable populations.

Background: Vital signs and neurologic assessments are currently performed using the schedule utilized during the clinical trials which led to the approval of alteplase for acute stroke. These assessments can be disruptive to patients and represent a considerable staffing and infrastructural demand. While the goal of this approach is to improve outcomes by rapidly detecting actionable changes, its impact has been questioned. Despite its widespread use there has been limited systematic review regarding its influence on outcomes. Purpose: This project’s aim was to determine the impact of these assessments by conducting a retrospective review at our large, urban, comprehensive stroke center. We sought to evaluate the rate of compliance with established guidelines, and assess its correlation with patient outcomes. Methods: This retrospective review of patients receiving alteplase for acute stroke was approved by our institutional review board. A total of 130 patients were identified during 2018. Data was collected from the electronic medical record and The Get with the Guidelines database. Results: Our institutional guideline includes a total of 36 vital signs and 24 neurological assessments during first 24-hours after alteplase administration, for a total of 60 assessments. 63% of patients had full compliance with all 60 assessments. The discharge modified Rankin scale (mRS) for those with full compliance was 2.35 versus 2.31 for patients without 100% compliance (p>0.05; NS). There was less compliance with vital signs compared to neurological assessments (73.8% versus 76.9%). Conclusions: The majority of patients were complaint with all assessments however a notable portion missed at least one assessment, occurring more frequently with vital signs. Full compliance with all assessments was not associated with improved mRS.

Background and Purpose— Mild stroke is the most common cause for thrombolysis exclusion in patients acutely presenting to the hospital. Thrombolysis administration in this subgroup is highly variable among different clinicians and institutions. We aim to study the predictors of thrombolysis in patients with mild ischemic stroke in the FL-PR CReSD registry (Florida-Puerto Rico Collaboration to Reduce Stroke Disparities). Methods— Among 73 712 prospectively enrolled patients with a final diagnosis of ischemic stroke or TIA from January 2010 to April 2015, we identified 7746 cases with persistent neurological symptoms and National Institutes of Health Stroke Scale ≤5 who arrived within 4 hours of symptom onset. Multilevel logistic regression analysis with generalized estimating equations was used to identify independent predictors of thrombolytic administration in the subgroup of patients without contraindications to thrombolysis. Results— We included 6826 cases (final diagnosis mild stroke, 74.6% and TIA, 25.4%). Median age was 72 (interquartile range, 21); 52.7% men, 70.3% white, 12.9% black, 16.8% Hispanic; and median National Institutes of Health Stroke Scale, 2 (interquartile range, 3). Patients who received thrombolysis (n=1281, 18.7%) were younger (68 versus 72 years), had less vascular risk factors (hypertension, diabetes mellitus, and dyslipidemia), had lower risk of prior vascular disease (myocardial infarction, peripheral vascular disease, and previous stroke), and had a higher presenting median National Institutes of Health Stroke Scale (4 versus 2). In the multilevel multivariable model, early hospital arrival (arrive by 0–2 hours versus ≥3.5 hours; odds ratio [OR], 8.16; 95% confidence interval [CI], 4.76–13.98), higher National Institutes of Health Stroke Scale (OR, 1.87; 95% CI, 1.77–1.98), aphasia at presentation (OR, 1.35; 95% CI, 1.12–1.62), faster door-to-computed tomography time (OR, 1.81; 95% CI, 1.53–2.15), and presenting to an academic hospital (OR, 2.02; 95% CI, 1.39–2.95) were independent predictors of thrombolysis administration. Conclusions— Mild acutely presenting stroke patients are more likely to receive thrombolysis if they are young, white, or Hispanic and arrive early to the hospital with more severe neurological presentation. Identification of predictors of thrombolysis is important in design of future studies to assess the use of thrombolysis for mild stroke.

The CT angiography (CTA) spot sign is a strong predictor of hematoma expansion in intracerebral hemorrhage (ICH). However, CTA parameters vary widely across centers and may negatively impact spot sign accuracy in predicting ICH expansion. We developed a CT iodine calibration phantom that was scanned at different institutions in a large multicenter ICH clinical trial to determine the effect of image standardization on spot sign detection and performance. A custom phantom containing known concentrations of iodine was designed and scanned using the stroke CT protocol at each institution. Custom software was developed to read the CT volume datasets and calculate the Hounsfield unit as a function of iodine concentration for each phantom scan. CTA images obtained within 8 h from symptom onset were analyzed by two trained readers comparing the calibrated vs. uncalibrated density cutoffs for spot sign identification. ICH expansion was defined as hematoma volume growth >33%. A total of 90 subjects qualified for the study, of whom 17/83 (20.5%) experienced ICH expansion. The number of spot sign positive scans was higher in the calibrated analysis (67.8 vs 38.9% p

In the latest American Heart Association/American College of Cardiology/Heart Rhythm Society atrial fibrillation (AF) guidelines, CHA 2 DS 2 -VASc replaced the CHADS 2 stroke risk assessment to determine prophylactic anticoagulation, reflecting female gender's association with stroke incidence in AF. However, little investigation has been pursued of potential risk factors associated with worsened stroke severity. In this study, we examined patients with AF with ischemic stroke patient characteristics associated with increased stroke severity. Using the Get With The Guidelines-Stroke database, we retrospectively identified 221 consecutive patients with AF diagnosed with acute ischemic stroke and performed in depth chart review, evaluating demographics, labs, and co-morbidities. We analyzed the modified Rankin Scale (mRS) at discharge as a surrogate for stroke severity, defining severe stroke as fatal (mRS of 6) or disabling (mRS 4 to 5), requiring max assistance with ambulation or activities of daily living. Female gender, advanced age, and decreased body surface area were associated with disabling or fatal stroke (68.3% of patients with mRS 4 to 6 vs 50% with mRS 0 to 3, 78.4 vs 71.1 year, and 1.83 vs 1.92, respectively). Using a backward elimination approach revealed a logistic regression model with statistically significant odds ratios (ORs) for female gender (OR 1.99) and age (OR 1.04), and borderline significant for a history of coronary artery disease (OR 1.89). In conclusion, female gender is associated in the AF population with a twofold risk of severe disabling or fatal ischemic stroke, a finding that persists after controlling for potential confounders. This finding highlights the potential benefit from appropriate anticoagulation use for stroke prophylaxis in the AF population.

For decades, neurologists have been advocating that anyone with acute focal deficits report immediately to the closest hospital’s emergency room. Major advancements in the hyperacute diagnosis and treatment of stroke have justified our call-to-action slogan of “Time is Brain”—faster therapy leads to superior outcomes. However, this mantra has been recently usurped by the catchphrase “Stay at Home” during the coronavirus disease 2019 (COVID-19) pandemic. Fewer patients are presenting to hospitals with acute stroke; our census is down. Presumably the etiology of this phenomenon is either strict “social distancing” that some people may misperceive to exclude even emergent situations, or fears of contracting the virus while hospitalized. In this Short Report, we describe the year-over-year drop in stroke volume (ischemic and hemorrhagic both) coinciding with a paradoxical rise in acute reperfusion therapies at our university hospital. These data imply that stroke patients with mild/moderate symptoms are most likely staying home, and not receiving urgent therapies, and correspondingly, only the most severely disabled stroke patients are ultimately seeking and receiving help. We must remind our patients and the general public that our services are essential and available, as stroke still remains a medical emergency, and carries a likely higher overall mortality risk than COVID-19. As neurologists, we also must be vigilant for the atypical presentations and varied etiologies of stroke associated with COVID-19 as well.

Background: Optimal timing to initiate anticoagulation after acute ischemic stroke (AIS) from atrial fibrillation (AF) is currently unknown. Compared to other stroke etiologies, AF typically provokes larger infarct volumes and greater concern of hemorrhagic transformation, so seminal randomized trials waited weeks to months to begin anticoagulation after initial stroke. Subsequent data are limited and non-randomized. Guidelines suggest anticoagulation initiation windows between 3 and 14 days post-stroke, with Class IIa recommendations, and level of evidence B in the USA and C in Europe. Aims: This open-label, parallel-group, multi-center, randomized controlled trial AREST (Apixaban for Early Prevention of Recurrent Embolic Stroke and Hemorrhagic Transformation) is designed to evaluate the safety and efficacy of early anticoagulation, based on stroke size, secondary prevention of ischemic stroke, and risks of subsequent hemorrhagic transformation. Methods: Subjects are randomly assigned in a 1:1 ratio to receive early apixaban at day 0–3 for transient ischemic attack (TIA), 3–5 for small-sized AIS (

Background Gait impairment is a common consequence of stroke and typically involves a hemiparetic or asymmetric walking pattern. Asymmetric gait patterns are correlated with decreased gait velocity and efficiency as well as increased susceptibility to serious falls and injuries. Research Question This paper presents an innovative device worn on a foot for gait rehabilitation post stroke. The device generates a backward motion to the foot, which is designed to exaggerate the existing step length asymmetry while walking over ground. We hypothesize this motion will decrease gait asymmetry and improve functional walking in individuals with chronic stroke. Methods Six participants with chronic stroke, more than one year post stroke, received four weeks of gait training with three sessions per week. Each session included 30 min of walking over ground using the wearable device. Gait symmetry and functional walking were assessed before and after training. Results All participants improved step length symmetry, and four participants improved double limb support symmetry. All participants improved on all three functional outcomes (gait velocity, Timed Up and Go Test, and 6-Minute Walk Test), and five participants improved beyond the minimal detectable change or meaningful change in at least one functional outcome. Conclusion The results indicate that the presented device may help improve stroke patients’ walking ability and warrant further study. A gait training approach using this new device may enable and expand long-term continuous gait rehabilitation outside the clinic following stroke. Trial registration NCT02185404. Registered July 9, 2014, https://clinicaltrials.gov/ct2/show/NCT02185404

We present the case of an 18-year-old woman with B-cell acute lymphoblastic leukemia (ALL) who developed hemorrhagic stroke and epilepsia partialis continua due to acute cerebral vein thrombosis (CVT). The patient had 10 risk factors for CVT (including use of asparaginase chemotherapy for the ALL) and also unfortunately had 4 biomarkers for poor prognosis for outcome post-CVT diagnosis. Immediate transfer to a Comprehensive Stroke Center allowed for hyperacute neurointerventional clot extraction with rapid restoration of the patency of the superior sagittal sinus. This resulted in an unexpectedly favorable neurological outcome and simultaneously allowed for early resumption of chemotherapy for ALL after only a 5-day hiatus. Our case highlights the importance of immediate transfer of highest risk patients with multiple biomarkers for poor prognosis to a Comprehensive Stroke Center with endovascular and neurosurgical capabilities and the possibility of overcoming the odds of a poor outcome with venous clot extraction if medical management fails. Neurological deterioration due to escalating intracranial pressure with impending herniation may occur rapidly, and treatment at such facilities can be life-saving.

Background and Purpose— Ischemic stroke (IS) secondary to atrial fibrillation (AF) is largely preventable with the use of anticoagulation. We sought to identify race-ethnicity and sex disparities with the use of direct oral anticoagulants (DOACs), aspirin, and warfarin in IS patients with AF and to identify temporal trends in the utilization of these medications. Methods— The FLiPER-AF Stroke Study (Florida Puerto Rico Atrial Fibrillation) included 24 040 IS cases enrolled in the Florida-Puerto Rico Collaboration to Reduce Stroke Registry from 2010 to 2016. Multivariable logistic regression models were performed to evaluate the effect of race-ethnicity and sex on utilization of DOACs, aspirin, and warfarin for stroke prevention in AF after adjustment for sociodemographic, hospital, and clinical factors. Results— Among 24 040 IS cases, 54% were women and 10% black, 12% FL-Hispanics, 4% PR-Hispanic, and 74% whites. From 2010 to 2016, DOAC use increased from 0% to 36%, warfarin use decreased from 51% to 17%, and aspirin use remained relatively stable (42%–40%). After adjustment, blacks had higher odds of warfarin (odds ratio, 1.22; 95% CI, 1.07–1.40) prescription at discharge compared with whites. Men had higher rates of aspirin (42.1% versus 38.8%), warfarin (33.6% versus 28.9%), and DOAC (21.3% versus 19.3%) use compared with women. After adjustment, women had lower odds of being discharged on aspirin (odds ratio, 0.92; 95% CI, 0.86–0.98) or warfarin (odds ratio, 0.91; 95% CI, 0.84–0.99). There was no sex difference in use of DOACs. Conclusions— Our study confirmed the increasing use of DOACs, downtrending use of warfarin, whereas aspirin use remained similar over the years. There are sex and race-ethnicity disparities in anticoagulation use in IS patients with AF. It is critical to understand underlying drivers of these disparities to develop better practice strategies for stroke prevention in patients with AF. Clinical Trial Registration— URL: https://www.clinicaltrials.gov . Unique identifier: NCT03627806.

Background: Most stroke patients have their stroke in the community setting, however a significant minority occur while hospitalized for another condition. Prior studies have noted worse outcomes for in-hospital strokes(IHS) compared to community-onset strokes(COS). IHS are also less likely to receive intravenous thrombolytic therapy. The increased use of mechanical thrombectomy(MT) and distinct eligibility criteria from thrombolysis provide additional therapy options for these patients. We present one of the first comparison of outcomes looking specifically at MT for IHS versus COS. Methods: We performed an IRB-approved, retrospective cross-sectional study on patients who underwent MT at our center for acute ischemic stroke between Jan 2012 and Nov 2017. Variables reviewed included patient demographics, vascular risk factors, symptom recognition time, treatment time, and disability as measured by the Modified Rankin Scale(mRS). Statistical analyses were performed using logistic regression to assess the relationship between IHS versus COS. Results: We studied 334 patients (290 COS and 44 IHS) who were treated with MT for acute ischemic stroke. Patients who presented in-hospital were younger (60.7 vs. 70.4 years; p Conclusion: In conclusion, time from symptom recognition to MT is faster for IHS vs. COS. In addition, IHS had less disability after mechanical thrombectomy for large vessel occlusion.

Background: Despite the efficacy of Direct Oral Anticoagulants (DOACs) in Nonvalvular Atrial Fibrillation (NVAF), some patients may still develop an ischemic stroke while taking this medication. This can be from a primary efficacy problem, called DOAC “True failure” (due to drug absorption, metabolism, or clearance), or DOAC “Pseudo-failure” (due to alternate causes of stroke, not the NVAF). We aim to study the factors contributing to DOAC Pseudo-failures and isolate DOAC True Failure rates. Methods: IRB-approved, retrospective study of NVAF patients on DOAC who developed ischemic stroke between Jan 2012 and Dec 2017. Variables reviewed include DOAC Pseudo-failure causes listed in the mnemonic CHAMP: C for Compliance concerns (adherence [held for procedure, ran out, or discontinued], incorrect dose, or incorrect frequency [QD vs BID]); H for Hypertensive lacunar disease; A for Arterial diseases (such as Atherosclerosis [intra- or extra-cranial, carotid or vertebral arterial stenosis or dissection]); M for Malignant cancer or other hypercoagulable states; and P for Patent Foramen Ovale (PFO). Results: We identified 87 NVAF patients on DOAC who presented with ischemic stroke: 18 on Dabigatran, 37 on Apixaban and 32 on Rivaroxaban. Of those, 67 patients (77%) had at least one of the CHAMP variables (DOAC Pseudo-failure) while 20 (23%) were DOAC True failures. Compliance concerns were responsible for nearly half (49%) of the Pseudo-failures, followed by Malignancy/hypercoagulability (26%), Arterial disease (17%), HTN (5.7%) and PFO (2.3%). True Failure was lowest for Dabigatran (5.6%) followed by Apixaban (16%) and highest with Rivoraxaban (41%) despite its high compliance rate of 66%. Compliance for the BID DOACs (Dabigatran and Apixaban) were similar at 39 % and 43%, respectively. Conclusion: Patients on DOAC for NVAF who develop ischemic stroke are three times more likely to have another identifiable etiology. Compliance concerns, Cancer/Hypercoagulability, and arterial disease represent over 90% of DOAC Pseudo-failures. Thus, providers should educate patients on correct DOAC doses and frequencies, and screen presumed DOAC failures with scans of the chest, abdomen and pelvis in addition to intracranial and extracranial vessel imaging.

Background: Ischemic stroke (IS) is a known effect of atrial fibrillation (AF) and is largely preventable with the use of systemic anticoagulation. Direct oral anticoagulants (DOACs) effectively prevent IS in patients with AF, but DOAC utilization patterns vary. The goal of this study is to identify race-ethnic and sex disparities for the use of DOACs, aspirin, and warfarin at hospital discharge in IS patients with AF, and to identify temporal trends in the utilization of these medications in a large hospital stroke registry in Florida and Puerto Rico. Methods: The FLorida PuErto Rico Atrial Fibrillation (FLiPER-AF) Stroke Study included 28,036 IS cases enrolled in the Florida-Puerto Rico Collaboration to Reduce Stroke Registry from 2010 to 2017. Multivariable logistic regression models were performed to evaluate the effect of race-ethnicity and sex on utilization of DOACs, aspirin and warfarin for stroke prevention in AF after adjustment for systems of care, individual and clinical factors, including CHA2DS2-VASc scores. Results: Among 28,036 IS cases, 74% were women and 9.9% Black, 12.5% FL Hispanics, 3.3% PR Hispanic and 74.3% whites. Overall, DOAC use increased from 0% in 2010 to 44.3% in 2017, while warfarin use decreased from 55.0% to 13.5%, in 2010 and 2017, respectively. Aspirin use remained stable overall, 42.3% in 2010 and 43.8% in 2017. After adjustment, Blacks had lower odds of being discharged on DOACs (OR=0.85, 95% CI 0.77-0.94) and higher odds of being discharged on warfarin (OR=1.13, 95% CI 1.02-1.25) compared to Whites. Men had higher rates of aspirin (42.1% vs 38.8%), warfarin (33.6% vs. 28.9%) and DOAC (21.3% vs, 19.3%) prescription compared to women. After adjustment, women had lower odds of being discharged on aspirin (OR=0.91, 95% CI 0.86-0.96) or warfarin (OR=0.90, 95% CI 0.85-0.96); however, there was no difference in use of DOACs. Conclusions: Our study confirmed the increasing use of DOACs and down-trending use of warfarin in IS patients with AF. However, Blacks were discharged on DOACs less frequently than Whites and women were discharged on anticoagulation less frequently than men. Further studies to understand underlying drivers of these disparities are needed to develop better practice strategies for stroke prevention for AF.

Background: Despite widespread use of Intravenous thrombolysis (IVT) for acute ischemic stroke (AIS), little is known about the frequency and etiologies of early readmission rates to the hospital soon after initial discharge. Understanding the causes associated with 30-day readmissions following IVT is critical to reduce cost and improving the quality of life in AIS patients. Methods: Nationwide Readmissions Database (NRD) from 2010-14 was utilized to identify AIS and IVT using appropriate ICD-9CM codes in primary diagnosis and ICD9 procedure code 99.10 in any procedural field. Admissions within 30 days of discharge were considered as early readmission. Readmission causes were identified by ICD 9 CM code in primary diagnosis field of readmissions. P values for trends were generated by Cochrane-Armitage test for categorical variables and simple linear regression for continuous variables. Results: We identified 164,007 AIS patients undergoing IVT (Mean age=69.5 years,49.6% Female) of which 10.9% (N=17,844) were readmitted. Significant decline in readmission rate has been observed during our study period (from 11.8% in 2010 to 10.4% in 2014, Ptrend = Conclusion: About 1 in 10 patients who received IVT for AIS are prone to get readmitted within 30 days, most likely secondary to neurological or cardiac complications. Additional interventions, consultations or workup may be warranted to recognize and mitigate preventable post-thrombolysis readmissions.

Objectives: Up to 41% of intracerebral hemorrhages (ICH) are considered cryptogenic despite a thorough investigation to determine etiology. Certain over-the-counter supplements may increase proclivity to bleeding, and we hypothesize that specifically vitamin E may have an association with ICH and acutely elevated serum levels of α-tocopherol. Our aim is to report 3 cases of recently admitted patients with hypervitaminosis E and otherwise cryptogenic ICH. Methods: At our institution between January and December 2018, 179 patients were admitted with ICH with 73 imputed to be “cryptogenic” (without clear etiology as per Structural vascular lesions, Medication, Amyloid angiopathy, Systemic disease, Hypertension, or Undetermined and Hypertension, Amyloid angiopathy, Tumor, Oral anticoagulants, vascular Malformation, Infrequent causes, and Cryptogenic criteria). Of these, we found 3 (4.1%) clearly admitted to consistent use of vitamin E supplementation for which α-tocopherol levels were checked. We describe the clinical presentation and course of these patients and their etiologic and diagnostic evaluations including neuroimaging and α-tocopherol laboratory data. Results: All patients in this series were consistently consuming higher than recommended doses of vitamin E and developed acute ICH. The first 2 patients both had subcortical (thalamic) intraparenchymal hemorrhages while the third had an intraventricular hemorrhage. Serum α-tocopherol levels in patient A, B, and C were elevated at 30.8, 46.7, and 23.3 mg/L, respectively (normal range 5.7-19.9 mg/L) with a mean of 33.6 mg/L. No clear alternate etiologies to their ICH could be conclusively determined despite thorough workups. Conclusions: In patients with cryptogenic ICH, clinicians should consider hypervitaminosis E and check serum α-tocopherol level during admission. Reviewing the patient's pharmacologic history, including over-the-counter supplements such as vitamin E, may help identify its association, and its avoidance in the future may mitigate risk. With its known vitamin K antagonism, hypo-prothrombinemic effect, cytochrome p-450 interaction, and antiplatelet activity, vitamin E may not be as benign as presumed. Its consumption in nonrecommended doses may increase ICH risk, which may be underestimated and under-reported.

Chinese Licorice root “gan zao” (Glycyrrhiza uralensis) is an ancient, medicinal herb utilized in Traditional Chinese Medicine for its presumably antiulcer, anti-inflammatory, antiviral, antibacterial, and expectorant properties. One of the major biologically active components is glycyrrhizin, which when hydrolyzed to glycyrrhetinic acid in the human body, possesses significant hypertensive effects due to interaction with the enzyme 11-β-hydroxysteroid dehydrogenase-2.(1) Glycyrrhizin and glycyrrhetinic acid also show antithrombotic properties, as orally active, direct inhibitors of blood coagulation factor Xa as well as of thrombin.(2) To our knowledge, this is the first reported case of intracranial hemorrhagic stroke associated with Chinese Licorice Root, and first reported case of cerebral microbleeds (CMB) associated with it as well.

Constitutional chromoanagenesis events, which include chromoanasynthesis and chromothripsis and result in highly complex rearrangements, have been reported for only a few individuals. While rare, these phenomena have likely been underestimated in a constitutional setting as technologies that can accurately detect such complexity are relatively new to the mature field of clinical cytogenetics. G-banding is not likely to accurately identify chromoanasynthesis or chromothripsis, since the banding patterns of chromosomes are likely to be misidentified or oversimplified due to a much lower resolution. We describe a patient who was initially referred for cytogenetic testing as a child for speech delay. As a young adult, he was referred again for recurrent strokes. Chromosome analysis was performed, and the rearrangement resembled a simple duplication of 13q32q34. However, SNP microarray analysis showed a complex pattern of copy number gains and a loss consistent with chromoanasynthesis involving distal 13q (13q32.1q34). This report emphasizes the value of performing microarray analysis for individuals with abnormal or complex chromosome rearrangements.

Background: Patients with minor ischemic stroke were largely excluded from the randomized trials of endovascular therapy (EVT) in stroke. In the Florida-Puerto Rico Registry we sought to determine the utilization of EVT in this population. Methods: From January 2010 to March 2017, 57,750 acute ischemic stroke patients within 24 hours of symptom onset were prospectively included from 88 sites in four Florida regions (south, west central, north and panhandle, east central) and Puerto Rico. Differences between minor (NIHSS ≤ 5) and moderate/severe (NIHSS>5) stroke patients who received EVT were evaluated using multivariable logistic regression with generalized estimating equations. Results: Among 2,845 EVT patients (50% women, mean age ±SD 71±14 years), 347 (12%) had NIHSS ≤ 5. As compared to NIHSS>5, minor stroke patients were younger (mean age 67 vs. 71, p5. Majority of minor stroke patients who received EVT were discharged home or to rehab (75%) while 53% of those with NIHSS>5. Conclusions: More than 1 in 10 cases that received EVT had mild neurological symptoms. Many factors including hospital expertise and time of presentation affect the use of this treatment. Further study of EVT in minor stroke is warranted.

Background: Among stroke survivors, worse functional outcomes have been reported in race/ethnic minority groups. Race/ethnic differences in post-stroke independent ambulation may be evident early and largely influenced by age. Independent ambulation is defined as the ability to walk without supervision or assistance from another person. Discharge ambulation status may have implications for long term rehabilitation after stroke. We sought to determine the impact of age on race/ethnic differences in discharge ambulation status in the large NINDS-funded FL-PR CReSD Registry of Get With The Guidelines-Stroke (GWTG-S) data. Methods: Discharge ambulation status was analyzed for 51,859 acute ischemic stroke (AIS) survivors from 69 FL and 13 PR sites. Multivariate logistic regression models were used to test whether age modifies the relationship between race/ethnicity and independent ambulation at discharge (IAD). Stratified analyses were performed in 3 age groups: 18-64, 65-79, 80+. Models were adjusted for sex, vascular risk factors, independent ambulation status at admission and hospital characteristics. Results: IAD was achieved in 52%, of which 71% were non-Hispanic White (NHW), 13% NH Black (NHB), 12% FL Hispanic (FLH), and 4% PR Hispanic (PRH). IAD was most common in NHW (57%), followed by FLH (53%), NHB (47%), and PRH (40%). Older age was associated with lower odds of IAD (18-64: 68%, 65-79: 54%, 80+: 32%). After full adjustment, IAD was less likely in older [65-79 vs 18-64: OR 0.68, 95% CI 0.63-0.73; 80+: OR 0.35, 95% CI 0.32-0.39] and NHB vs. NHW patients [OR 0.85, 95% CI 0.78-0.92]. In age-stratified analyses, NHBs were less likely than NHWs to achieve IAD among those age 65-79 (47% vs. 57%) and 80+ (29% vs 34%) [OR 0.79, 95% CI 0.70-0.90; OR 0.76, 95% CI 0.65-0.88]. This association was not seen in the 18-64 age group (66% vs 69%), [OR 0.97, 95% CI 0.88-1.06]. Conclusions: About half of AIS survivors are unable to ambulate independently after stroke at discharge. Elderly NHB are less likely to IAD, though the disparity is not observed in working age adults. Post-stroke ambulation is a public health issue that substantially contributes to the economic burden of US healthcare. Further studies are warranted to identify causes of race/ethnic disparities in IAD.

Introduction: Primary stroke center (PSC) and comprehensive stroke center (CSC) designation in Florida aims to improve delivery of care and outcomes for stroke patients. In line with the goals of the NINDS funded Florida-Puerto Rico Collaboration to Reduce Stroke Disparities (FL-PR CReSD) Study, we sought to compare ischemic stroke performance metrics by stroke center designation in participating Florida hospitals. Methods: We analyzed 74,623 cases with acute ischemic stroke from 26 CSC and 40 PSC from January 2010-April 2016. We described patient demographics, comorbidities and Get With The Guidelines-Stroke performance metrics of defect free care (compliance with 7 pre-defined performance core measures), door to CT time (DTCT) ≤25 mins and door to needle time (DTN) ≤60 mins. Results: Compared with PSC patients, CSC patients were younger (70 ± 15 vs. 71 ± 14 years, p; < 25 mins 33% vs. 31%, p Conclusion: Patients treated in CSC, compared with those treated in PSC, received better defect-free care and had lower DTCT and DTN times. Race-ethnic disparities in performance metrics are still evident in both CSC and PSC. Identification of these disparities is important to design interventions to reduce disparities and improve stroke quality of care for all.

Background and Purpose: Endovascular thrombectomy improves functional outcome in select ischemic stroke patients. In the NINDS-funded CReSD Registry we sought to determine the clinical, hospital and regional characteristics associated with use of this therapy in patients presenting with acute ischemic stroke. Methods: Ischemic stroke patients within 24 hours of onset were prospectively included from 82 sites in Florida and Puerto Rico from January 2010 to April 2016. Independent predictors of endovascular therapy were evaluated using multivariable logistic regression with generalized estimating equations. Results: Among 58,204 patients with acute ischemic stroke (50% male, 65% white, 15% black, 20% Hispanic, mean age±SD 71±14 yrs), 2105 (3.6%) received endovascular thrombectomy (50.9% men, 62.3% white, 13.7% black, 24% Hispanic, mean age±SD 70±15yrs) with (35.2%) or without intravenous thrombolysis. Patients who received endovascular therapy had a significantly lower risk of vascular risk factors except for Afib (33.7% vs 19.0%), more severe strokes (median NIHSS 15 vs. 5) and were more likely to arrive quickly (126 min vs. 210 min), via EMS (70.4% vs. 59.6%) or as a transfer from another hospital (20.8% vs 5.8%,) during working hours (47.7% vs. 45.6%), to large hospitals (≥ 680 beds) (48.3% vs 28.8%), and treated in South Florida (47.3% vs. 35.9%) as compared to those not receiving this treatment. In multivariable analysis; age (OR 0.97, 95% CI 0.96- 0.98), Blacks (OR 0.68, 95% CI 0.56-2.28) vs. White, off-hour presentation (OR 0.76, 95% CI 0.66- 0.96), to regions other than South Florida (North OR 0.40, 95% CI 0.17-0.93, Panhandle OR 0.12, 95% CI 0.04-0.36) remained independently associated with lower use of endovascular therapy. In contrast, Hispanics (OR 1.28, 95% CI 1.03- 1.69) vs. White and presenting to large hospital (OR 4.92, 95% CI 1.05- to 22.6) were associated with higher use of endovascular treatment. Conclusions: There are significant race, regional and hospital disparities in delivery of endovascular care. Efforts should me made to improve access to endovascular treatment in patients presenting across the region to all stroke centers.

Objective: We aimed to determine factors associated with recent infarct (RI) in patients with newly identified atherosclerotic cervical internal carotid artery occlusion (CICAO). Methods: This was a retrospective review of consecutive patients who underwent cervical CT angiography from 2002 to 2006 at a single tertiary center. RI was defined by positive diffusion-weighted imaging/apparent diffusion coefficient magnetic resonance imaging (MRI) in the correspondent CICAO territory. Subjects were dichotomized into those with a RI versus patients with no RI (No-RI). Results: Of 2,459 patients with cervical CT angiograms in the study period, 108 (4.4%) had complete medical records and brain MRI and were included. The mean age was 64 ± 13 years, 58% were men, and 62 (57%) had a RI. The demographics of the RI and No-RI patients were comparable, with the exception that those with RI had a lower frequency of coronary artery disease (CAD, 13 vs. 54%; p < 0.01) and dyslipidemia (38 vs. 69%; p < 0.01). The use of antiplatelets was not statistically different between the groups (56 vs. 71%; p = 0.1). Subjects with RI were less likely on statins (21 vs. 56%; p < 0.01) and antihypertensives (9 vs. 71%; p < 0.01). Multivariate regression revealed that CAD, the use of statins, and the use of antihypertensives were associated with No-RI CICAO presentation. Conclusion: The use of statins and antihypertensives is associated with a decreased risk of RI atherosclerotic CICAO.

Background and Purpose— In the United States, about half of acute ischemic stroke patients treated with tPA (tissue-type plasminogen activator) receive treatment within 60 minutes of hospital arrival. We aimed to determine the proportion of patients receiving tPA within 60 minutes (door-to-needle time [DTNT] ≤60) and 45 minutes (DTNT ≤45) of hospital arrival by race/ethnicity and sex and to identify temporal trends in DTNT ≤60 and DTNT ≤45. Methods— Among 65 654 acute ischemic stroke admissions in the National Institute of Neurological Disorders and Stroke-funded FL-PR CReSD study (Florida-Puerto Rico Collaboration to Reduce Stroke Disparities) from 2010 to 2015, we included 6181 intravenous tPA-treated cases (9.4%). Generalized estimating equations were used to determine predictors of DTNT ≤60 and DTNT ≤45. Results— DTNT ≤60 was achieved in 42% and DTNT ≤45 in 18% of cases. After adjustment, women less likely received DTNT ≤60 (odds ratio, 0.81; 95% confidence interval, 0.72–0.92) and DTNT ≤45 (odds ratio, 0.73; 95% confidence interval, 0.57–0.93). Compared with Whites, Blacks less likely had DTNT ≤45 during off hours (odds ratio, 0.68; 95% confidence interval, 0.47–0.98). Achievement of DTNT ≤60 and DTNT ≤45 was highest in South Florida (50%, 23%) and lowest in West Central Florida (28%, 11%). Conclusions— In the FL-PR CReSD, achievement of DTNT ≤60 and DTNT ≤45 remains low. Compared with Whites, Blacks less likely receive tPA treatment within 45 minutes during off hours. Treatment within 60 and 45 minutes is lower in women compared with men and lowest in West Central Florida compared with other Florida regions and Puerto Rico. Further research is needed to identify reasons for delayed thrombolytic treatment in women and Blacks and factors contributing to regional disparities in DTNT.