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Introduction Although intravenous thrombolysis (IVT) represents standard‐of‐care treatment for acute ischemic stroke (AIS) in eligible adult patients, definitive evidence‐based guidelines and randomized clinical trial data evaluating its safety and efficacy in the pediatric population remain absent from the literature. We aim to evaluate the utilization and outcomes of IVT for the treatment of pediatric AIS using a large national registry. Methods Weighted hospitalizations for pediatric ( Results Among 13,901 pediatric AIS patients, 270 (1.9%) were treated with IVT monotherapy (median age 12.8 years). IVT‐treated patients developed any intracranial hemorrhage (ICH) at a rate of 5.6% (n = 15), and 71.9% (n = 194) experienced favorable functional outcomes at discharge (to home or to acute rehabilitation). Following propensity‐score adjustment for age, acute stroke severity, infarct location, and etiological/comorbid conditions, IVT was not associated with an increased risk of any ICH [5.6% vs. 5.4%, p = 0.931; adjusted odds ratio (aOR) 1.01, 95% confidence interval (CI) 0.48, 2.14, p = 0.971], nor with favorable functional outcome (71.9% vs. 74.5%, p = 0.489; aOR 0.88, 95% CI 0.60, 1.29, p = 0.511) in comparison with other medical therapy. Conclusions Twenty years of population‐level data in the United States demonstrate that pediatric AIS patients treated with IVT experienced high rates of favorable outcomes without an increased risk of hemorrhagic transformation.

Background and Aims: Although intravenous thrombolysis (IVT) represents standard-of-care treatment for acute ischemic stroke (AIS) in eligible adult patients, definitive evidence-based guidelines and randomized clinical trial data evaluating its safety and efficacy in the pediatric population remain absent from the literature. We aimed to evaluate the utilization and outcomes of IVT for the treatment of pediatric AIS using a large national registry. Methods: Weighted hospitalizations for pediatric (Results: Among 13,901 pediatric AIS patients, 270 (1.9%) were treated with IVT monotherapy (median age 12.8 years). IVT-treated patients developed any intracranial hemorrhage (ICH) at a rate of 5.6% (n = 15), and 71.9% (n = 194) experienced favorable functional outcomes at discharge (to home or to acute rehabilitation). Following propensity-score adjustment for age, acute stroke severity, infarct location, and etiological/comorbid conditions, IVT was not associated with an increased risk of any ICH (5.6% vs 5.4%, p = 0.931; adjusted odds ratio (aOR) = 1.01, 95% confidence interval (CI) = 0.48–2.14, p = 0.971), nor with favorable functional outcome (71.9% vs 74.5%, p = 0.489; aOR = 0.88, 95% CI = 0.60–1.29, p = 0.511) in comparison with other medical therapy. Conclusions: Twenty years of population-level data in the United States demonstrate that pediatric AIS patients treated with IVT experienced high rates of favorable outcomes without an increased risk of hemorrhagic transformation.

Background: Previous literature has identified a survival advantage in acute ischemic stroke (AIS) patients with elevated body mass indices (BMIs), a phenomenon termed the “obesity paradox.” Objective: The aim of this study was to evaluate the independent association between obesity and clinical outcomes following AIS. Methods: Weighted discharge data from the National Inpatient Sample were queried to identify AIS patients from 2015 to 2018. Multivariable logistic regression and Cox proportional hazards modeling were performed to evaluate associations between obesity (BMI ≥ 30) and clinical endpoints following adjustment for acute stroke severity and comorbidity burden. Results: Among 1,687,805 AIS patients, 216,775 (12.8%) were obese. Compared to nonobese individuals, these patients were younger (64 vs. 72 mean years), had lower baseline NIHSS scores (6.9 vs. 7.9 mean score), and a higher comorbidity burden. Multivariable analysis demonstrated independent associations between obesity and lower likelihood of mortality (adjusted odds ratio [aOR] 0.76, 95% confidence interval [CI]: 0.71, 0.82, p < 0.001; hazard ratio 0.84, 95% CI: 0.73, 0.97, p = 0.015), intracranial hemorrhage (aOR 0.87, 95% CI: 0.82, 0.93, p < 0.001), and routine discharge to home (aOR 0.97, 95% CI: 0.95, 0.99; p = 0.015). Mortality rates between obese and nonobese patients were significantly lower across stroke severity thresholds, but this difference was attenuated among high severity (NIHSS > 20) strokes (21.6% vs. 23.2%, p = 0.358). Further stratification of the cohort into BMI categories demonstrated a “U-shaped” association with mortality (underweight aOR 1.58, 95% CI: 1.39, 1.79; p < 0.001, overweight aOR 0.64, 95% CI: 0.42, 0.99; p = 0.046, obese aOR 0.77, 95% CI: 0.71, 0.83; p < 0.001, severely obese aOR 1.18, 95% CI: 0.74, 1.87; p = 0.485). Sub-cohort assessment of thrombectomy-treated patients demonstrated an independent association of obesity (BMI 30–40) with lower mortality (aOR 0.79, 95% CI: 0.65, 0.96; p = 0.015), but not with routine discharge. Conclusion: This cross-sectional analysis demonstrates a lower likelihood of discharge to home as well as in-hospital mortality in obese patients following AIS, suggestive of a protective effect of obesity against mortality but not against all poststroke neurological deficits in the short term which would necessitate placement in acute rehabilitation and long-term care facilities.

BackgroundObstructive sleep apnea (OSA) portends increased morbidity and mortality following acute ischemic stroke (AIS). Evaluation of OSA in the setting of AIS treated with endovascular mechanical thrombectomy (MT) has not yet been evaluated in the literature.MethodsThe National Inpatient Sample from 2010 to 2018 was utilized to identify adult AIS patients treated with MT. Those with and without OSA were compared for clinical characteristics, complications, and discharge disposition. Multivariable logistic regression analysis and propensity score adjustment (PA) were employed to evaluate independent associations between OSA and clinical outcome.ResultsAmong 101 093 AIS patients treated with MT, 6412 (6%) had OSA. Those without OSA were older (68.5 vs 65.6 years old, pConclusionsOur findings suggest that MT is a viable and safe treatment option for AIS patients with OSA.

Objective: Community stroke education is a regulated, integral component of stroke systems of care. However, little is known about the types of activities conducted by hospitals. This study was designed to examine the annual requirement for community stroke education among New York State’s 119 designated Primary Stroke Centres and identify areas for improvement that may have an implication on stroke outcomes. Design: Cross-sectional survey design Setting: All 119 New York State designated Primary Stroke Centres were invited to participate. Methods: Participating hospitals completed a 29-item online questionnaire assessing multiple domains related to community stroke education including hospital characteristics, allocated resources, implementation barriers, current community stroke education practices and willingness to adopt best practice guidelines. Data were analysed using univariate descriptive and chi-square statistics. Results: Eighty-eight percent of hospitals completed the survey (105/119). Respondents were mostly stroke coordinators and stroke directors. Stroke outreach education was conducted two to four times per year in 58% of the hospitals ( n = 69). Community stroke education included behavioural risk factor modification, the detection of stroke risk through screening and stroke preparedness education at health fairs. Although 95% of hospitals ( n = 98) reported using at least one best practice approach for these activities, evaluation was generally poor, with only about 23% ( n = 24) implementing outcome-specific assessments. Major barriers to stroke outreach were inadequate staffing, time constraints and lack of funding. Conclusion: Hospital-driven community stroke education efforts occur infrequently and are poorly evaluated. This component of stroke systems of care would benefit from guidelines from regulatory agencies, which currently do not exist.

Introduction: Intracerebral hemorrhage (ICH) is the most severe subtype of stroke with a high mortality rate and majority of survivors suffering significant disability. The Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) study prospectively recruited 1000 white, 1000 black and 1000 Hispanic spontaneous ICH cases. Herein, we report the main results of the predictors of 3 month outcome after ICH. Hypothesis: We hypothesized that ICH Score variables of age, ICH volume, ICH location, presence of intraventricular hemorrhage (IVH), and presenting Glasgow Coma Scale would predict long-term disability in addition to prior validation of mortality. Methods: Between 2010-2015, cases were prospectively recruited with uniform phenotype definitions, centralized neuroimaging review and with telephone follow-up at 3 months. Apolipoprotein E genotyping was performed centrally. Individual characteristics were screened for association under a logistic regression model, 90-day mRS ≥ 4 versus 0-3, and those meeting P Results: The Table presents the prevalence/average of each variable entering the final multivariate model for association with poor (mRS 4-6) compared to good (mRS 0-3) outcome at 3 months. When analyses were repeated excluding withdrawal of care, overall Graeb (IVH) score fell out of the model (with presence of IVH replacing it) but the remaining variables were retained and in the same direction of effect. C-statistic for the multivariate model = 0.884 compared to 0.763 for ICH score alone (p=1.7E-22). Conclusion: ICH score elements were validated as predictive of 3 month outcome. Novel baseline characteristics such as white matter hyperintensity as well as subsequent clinical events that may affect outcomes were identified. Location specific results to be presented.

Background and Purpose— Less than 25% of stroke patients arrive to an emergency department within the 3-hour treatment window. Stroke Warning Information and Faster Treatment (SWIFT) compared an interactive intervention (II) with enhanced educational (EE) materials on recurrent stroke arrival times in a prospective cohort of multiethnic stroke/transient ischemic attack survivors. Methods— A single-center randomized controlled trial (2005–2011) randomized participants to EE (bilingual stroke preparedness materials) or II (EE plus in-hospital sessions). We assessed differences by randomization in the proportion arriving to emergency department Results— SWIFT randomized 1193 participants (592 EE, 601 II): mean age 63 years; 50% female, 17% black, 51% Hispanic, 26% white. At baseline, 28% arrived to emergency department P =0.33). In prepost analysis, there was a 49% increase in the proportion arriving P =0.001), greatest among Hispanics (63%, P Conclusions— There was no difference in arrival Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT00415389.

Background Our aim was to determine whether patients with embolic strokes of undetermined source ( ESUS ) have higher rates of elevated troponin than patients with noncardioembolic strokes. Methods and Results CAESAR (The Cornell Acute Stroke Academic Registry) prospectively enrolled all adults with acute stroke from 2011 to 2014. Two neurologists used standard definitions to retrospectively ascertain the etiology of stroke, with a third resolving disagreements. In this analysis we included patients with ESUS and, as controls, patients with small‐ and large‐artery strokes; only patients with a troponin measured within 24 hours of stroke onset were included. A troponin elevation was defined as a value exceeding our laboratory's upper limit (0.04 ng/mL) without a clinically recognized acute ST ‐segment elevation myocardial infarction. Multiple logistic regression was used to evaluate the association between troponin elevation and ESUS after adjustment for demographics, stroke severity, insular infarction, and vascular risk factors. In a sensitivity analysis we excluded patients diagnosed with atrial fibrillation after discharge. Among 512 patients, 243 (47.5%) had ESUS , and 269 (52.5%) had small‐ or large‐artery stroke. In multivariable analysis an elevated troponin was independently associated with ESUS (odds ratio 3.3; 95% confidence interval 1.2, 8.8). This result was unchanged after excluding patients diagnosed with atrial fibrillation after discharge (odds ratio 3.4; 95% confidence interval 1.3, 9.1), and the association remained significant when troponin was considered a continuous variable (odds ratio for log[troponin], 1.4; 95% confidence interval 1.1, 1.7). Conclusions Elevations in cardiac troponin are more common in patients with ESUS than in those with noncardioembolic strokes.

Background: Studies from Asia suggest that the overall proportion of hemorrhagic stroke is much higher compared to other parts of the world. We sought to evaluate the incidence of ischemic and hemorrhagic strokes in Asians living in the U.S. versus U.S. patients of other races and ethnicities. Methods: We identified all adult patients with acute ischemic or hemorrhagic stroke in the Nationwide Inpatient Sample from 2002-2011, using well-validated International Classification of Diseases, 9 th Revision, Clinical Modification ( ICD-9-CM ) diagnosis codes. Our predictor variable was self-reported Asian race. Our primary outcome was the relative proportion of hemorrhagic compared to ischemic strokes. Survey weights were used to account for the sampling methodology. Trend analysis was then performed using the Chi square test for linear association. Results: We included 4,449,516 patients in the U.S. with stroke, of whom 3,794,438 (85.3%) had ischemic stroke and 655,078 (14.7%) had hemorrhagic stroke. Of these patients, 98,964 (2.2%) were Asian. Amongst the entire sample of stroke patients, Asians had a higher proportion of hemorrhagic strokes compared to the general population (24.0% vs. 14.5%, p Conclusions: The incidence of hemorrhagic strokes appears to be higher among Asian compared to patients of other races and ethnicities in the U.S. Further study is warranted to delineate the role of genetic versus environmental factors in explaining the greater propensity to hemorrhagic as opposed to ischemic stroke in Asians.

Spinal vascular malformations are rare, with dural arteriovenous fistulas (AVFs) accounting for the majority of the pathology. Unlike spinal arteriovenous malformations, which cause abrupt neurological change as a result of hemorrhage, spinal dural AVFs tend to result in a progressive myelopathy through venous congestion and cord edema. If diagnosed and treated early with endovascular embolization or microsurgery, some deficits may be reversible.

Moyamoya is a rare cause of stroke caused by progressive distal carotid occlusion. Children and adults may be affected, but it is more common in Asian populations, particularly in patients presenting with intracranial hemorrhage. Angiographic findings of distal internal carotid artery stenosis with lenticulostriate or choroidal neocollaterals are important in the diagnosis of moyamoya disease. A similar pathophysiological state to moyamoya disease is associated with several clinical conditions, some of which are acquired and some of which have a genetic etiology. Treatment is with surgical revascularization, which can reduce both ischemic and hemorrhagic complications.

The diagnosis of a stroke mimic is typically made after the acute setting when the window for acute treatment has closed. Patients with stroke mimics who are eligible for tPA may safely be treated with a minimal risk of intracranial hemorrhage.

Patients with minor stroke symptoms or rapid improvement of symptoms are at high risk of subsequent worsening. Acute treatment with IV tPA is warranted if there is still a residual deficit that is disabling. Waiting for resolution of symptoms removes the possibility of some acute treatments that can only be administered within narrow time windows.

Hemorrhagic stroke is associated with high morbidity and mortality. A common cause of intracerebral hemorrhage (ICH) is hypertension. Patients with suspected ICH should be immediately evaluated with computed tomography (CT) scanning. If coagulopathic, correction of coagulopathy must be instituted rapidly. Hemorrhage due to hypertension usually occurs in subcortical locations. In patients with atrial fibrillation and ICH, a careful analysis of each individual’s risks and benefits must be performed prior to resuming anticoagulation for ischemic stroke prevention. Prevention involves aggressive blood pressure control.

Cognitive impairment is common following stroke. The clinical course and presentation are variable in vascular dementia, but the diagnosis can often be tied to recent vascular events or to progressive white matter lesions on MRI. Because there is considerable overlap between patients with vascular and Alzheimer’s type dementia, both acetylcholinesterase inhibitors and memantine have been tried off-label to treat the cognitive symptoms of vascular dementia with mixed results.

Spinal cord ischemia most often presents as an anterior spinal artery syndrome and involves watershed regions of the spinal cord. The clinical presentation and etiologies can be heterogeneous, but cord infarcts are typically the result of aortic surgeries, systemic hypotension, vertebral artery and aortic dissections, embolus, or vascular malformations. Given that it is a rare entity, involving symptoms that can progress over minutes to hours, a diagnosis is often delayed until after conventional windows for revascularization, including thrombolysis, have passed. Magnetic resonance imaging (MRI) is usually required to confirm the diagnosis.

Migraine may mimic stroke, but acute migraine can also be a (rare) cause of stroke, particularly in the posterior circulation. This risk is particularly high in patients who experience migraine aura, or in those who are smokers or who take oral contraceptives. Because this is a diagnosis of exclusion, other etiologies of stroke need to be investigated. Although there are no high-level clinical trial data, it is advised to control vascular risk factors and avoid medications that can potentially induce vasoconstriction in patients with migraine-related stroke.

Large middle cerebral artery (MCA) and cerebellar strokes can cause rapid neurological deterioration and death from edema, mass effect, and herniation. Hemicraniectomy in select patients with malignant MCA syndromes is life-saving, but patients are often left with significant disability. Younger patients may derive the most benefit from hemicraniectomy. Cerebellar strokes can also cause obstructive hydrocephalus, which may exacerbate herniation and brainstem compromise. Surgical decompression through suboccipital craniectomy relieves posterior fossa pressure and reduces mortality in these patients.

Carotid dissection should be considered as a stroke etiology, especially in young patients with a history of trauma. Carotid dissection can be recognized by exam findings and radiographic studies. Treatment can include aspirin or anticoagulation.

Intracranial aneurysms may be detected incidentally on imaging. Location and size of an intracranial aneurysm are helpful in stratifying risk of hemorrhage. Risk stratification is important for treatment decision-making. Modifiable risk factors associated with aneurysm growth and rupture (hypertension and tobacco use) should be addressed. Treatment needs to be individualized. Small aneurysms may be monitored. Surgery has been associated with neurological disability and cognitive impairment. Endovascular coiling may be associated with a higher rate of incomplete obliteration. There are no randomized trial data in patients with unruptured aneurysms.

Carotid stenosis is a risk factor for stroke. Revascularization of high-grade asymptomatic carotid stenosis in select patients can lower the risk of incident stroke. Endarterectomy and stenting are both associated with periprocedural risk. Risks and benefits need to be evaluated carefully before proceeding with any intervention. Certain patient demographic and clinical characteristics, such as female gender, may reduce the benefits of surgery and influence treatment decisions.

Posterior reversible encephalopathy syndrome is a clinical–radiographic syndrome of progressive headaches, blurred vision, confusion, and seizures in the setting of vasogenic edema on brain imaging, which is often localized to the posterior white matter. The symptoms are classically triggered by severe hypertension, pregnancy and the puerperium, or exposure to immunosuppressive medications. The symptoms can be reversible if the offending etiology is quickly removed, but permanent deficits can remain if strokes or hemorrhage complicate the clinical course.

Lacunar strokes are strongly associated with hypertension. Long-term blood pressure management is important after lacunar stroke. Antiplatelet therapy should be instituted for secondary stroke prevention.

Infective endocarditis can cause neurological complications, including stroke, hemorrhage, and mycotic aneurysms. Patients with endocarditis and neurological complications need vascular imaging to evaluate for aneurysm formation. Patients with acute ischemic stroke from septic emboli may not respond to conventional intravenous thrombolysis and have higher rates of hemorrhagic complications.

Sickle cell disease may result in large vessel intracranial stenoses, which cause high rates of stroke. Screening for elevated velocities on transcranial Dopplers is a good way to stratify stroke risk. Patients at high stroke risk should participate in an exchange transfusion program indefinitely to reduce the rate of subsequent stroke. Although there is a high risk of stroke in pediatric sickle cell patients, the use of IV tPA in this population is largely unstudied and not routinely recommended due to unclear safety and efficacy.

Aneurysmal subarachnoid hemorrhage typically causes sudden severe headache. Diagnosis is made by CT scan in most cases, but lumbar puncture may be needed if CT findings are normal and suspicion is high. Rapid evaluation and treatment are important because of the high morbidity and mortality associated with rebleeding and vasospasm.

Cerebral amyloid angiopathy (CAA) is more prevalent with advancing age. Recurrent lobar hemorrhage, microhemorrhages, and white matter disease may be seen. A presumptive diagnosis is made by clinical factors and imaging, and definitive diagnosis is by pathology. There is no specific medical therapy to prevent hemorrhages in CAA; however, blood pressure should be well controlled and anticoagulation avoided. There is no evidence that most patients with acute, superficial intracerebral hemorrhage respond to surgical evacuation using currently available invasive techniques; however, a subset of patients with good premorbid baseline may be considered for surgery if the hemorrhage is considered life-threatening.

Occult atrial fibrillation is more common than previously thought in patients with cryptogenic stroke, particularly in older cohorts. If stroke patients are suspected to have atrial fibrillation, intensive cardiac monitoring using implantable loop recorders or prolonged external monitors should be ordered and can result in higher rates of arrhythmia detection.

Advanced cancer is well known to cause a procoagulant state. The formation of sterile platelet thrombin vegetations on cardiac valves (i.e., nonbacterial thromboembolic disease) and arterial thrombosis are common etiologies of stroke in these patients. Despite preventative therapy with antiplatelet agents or low-molecular-weight heparins, stroke in cancer often portends a poor prognosis.

High-grade intracranial atherosclerosis is associated with a high risk of recurrent stroke. Medical therapy with antiplatelet therapy and aggressive risk factor control is the preferred treatment regimen for stroke prevention in patients with intracranial atherosclerosis. Current stenting techniques are associated with high morbidity and mortality.

Atrial fibrillation is a potent risk factor for stroke. Anticoagulation significantly lowers recurrent stroke risk in patients with atrial fibrillation. The novel oral anticoagulants offer options in addition to warfarin, and they are associated with lower risk of bleeding complications.

Patients with symptomatic carotid stenosis benefit from revascularization. The risk of recurrent stroke is highest during the early period after a transient ischemic attack or stroke. Carotid endarterectomy and carotid stenting are options for treatment and should be considered within the first 2 weeks if feasible.

Hypoxic–ischemic brain injury is common following cardiopulmonary arrest and is associated with high rates of mortality and morbidity. Therapeutic hypothermia has been helpful in increasing survival and functional outcomes in these patients. The neurological examination, neuroimaging studies, and ancillary serological and neurophysiological testing can be helpful in prognostication post-arrest.

Part of the “What Do I Do Now?” series, Cerebrovascular Disease uses a case-based approach to cover common and important topics in the examination, investigation, and management of stroke, embolism, thrombosis, hemorrhage, and other critical presentations of cerebrovascular disease. Each chapter provides a discussion of the diagnosis, key points to remember, and selected references for further reading. For this edition, all cases and references have been updated and new cases have been added, including the following: ischemic stroke in cancer, posterior reversible encephalopathy syndrome (PRES), primary angiitis of the central nervous system, symptomatic spinal vascular malformation, and vascular dementia. Cerebrovascular Disease is an engaging collection of thought-provoking cases that clinicians can utilize when they encounter difficult patients. The volume is also a self-assessment tool that tests the reader’s ability to answer the question, “What do I do now?”

Reversible cerebral vasoconstriction syndrome can cause thunderclap headache, subarachnoid hemorrhage, and stroke. The clinical presentation can be similar to aneurysmal subarachnoid hemorrhage and therefore requires rapid angiography. Angiographic findings of vasculopathy and resolution of clinical symptoms and imaging abnormalities support this diagnosis. This syndrome is most often incited following pregnancy or the ingestion of a vasoactive medication.

Primary angiitis of the central nervous system is a rare but often dramatic cause of ischemic and hemorrhagic stroke. Its varied clinical course, in combination with high false-negative rates of cerebral angiography and brain biopsy, makes it a difficult disease to definitively diagnosis. Consider a diagnosis of vasculitis in patients with atypical-appearing or multifocal vascular lesions, particularly if they involve both ischemic and hemorrhagic components. Central nervous system angiitis can result in a high degree of mortality and morbidity despite immunosuppressant therapy.

Blood pressure is commonly elevated after a stroke. There are theoretical risks of allowing very high blood pressures, but clinical data suggest early lowering of blood pressure may worsen outcomes.

There are many modifiable risk factors for stroke. Screening for risk factors in the primary care setting and instituting early lifestyle modification or medical treatment of risk factors will lower the risk of incident stroke.

A young patient without hypertension should have an evaluation for underlying cause of intracerebral hemorrhage. Arteriovenous malformations may cause intracerebral hemorrhage. Treatment can be challenging, and multimodal treatment is often required. The options include surgery, endovascular embolization, and radiotherapy.

Cavernous malformations may cause intracerebral hemorrhage and seizures. Surgical resection is considered in patients with accessible lesions and recurrent hemorrhage or refractory seizures. However, current nonrandomized data suggest that nonsurgical treatment of these lesions may be superior. Cavernous malformations may be familial.

Due to the brain’s inherent neuroplasticity, stroke patients can make major functional improvements during the first 3–6 months post-injury. Aggressive physical, occupational, and speech therapies should be focused to address individual patient needs. Depression is very common post-stroke, and if left untreated, it may lead to worsened functional outcomes. The development of spasticity post-stroke can impair motor recovery and should be treated with physiotherapy, oral antispasmodics, or local botulinum toxin injections, depending on the severity.

Traditional vascular risk factors such as hypertension, diabetes, and high cholesterol can contribute to stroke in young adults. In the absence of typical risk factors in a young patient, a more extensive evaluation is needed. Other, more unusual causes of stroke can include autoimmune, infectious, hematological, and toxic etiologies. Often, despite an exhaustive workup, the mechanism of stroke remains cryptogenic in younger patients.

Headache and hemorrhagic infarcts in patients who are hypercoagulable (including pregnancy and puerperium) should prompt an evaluation for dural venous sinus thrombosis. Intracranial venous thrombosis is a rare cause of stroke. Diagnosis is made with venous imaging such as magnetic resonance venography. Investigation for underlying prothrombotic state is needed. Treatment is typically with anticoagulation, despite hemorrhage on imaging.

Transient ischemic attack (TIA) is a risk factor for subsequent stroke. A TIA diagnosis should incorporate findings on brain MRI and noninvasive angiography, if available. Some patients with TIA are at high risk of early recurrence. Rapid evaluation and treatment reduce that risk. Some new data suggest that short-term dual antiplatelet therapy may reduce stroke recurrence in patients with TIA or minor stroke.

Intravenous tissue plasminogen activator (IV tPA) is the mainstay of stroke therapy and is US Food and Drug Administration-approved for the treatment of acute ischemic stroke. Its benefit on functional outcome has been established in multiple randomized trials when administered within 3 hours. Select patients may be treated off-label up to 4.5 hours from symptom onset. Eligibility criteria need to be reviewed carefully to optimize benefit and to minimize complications, namely reperfusion hemorrhage.

Atherosclerosis of the ascending aorta and arch can potentially lead to high rates of embolic stroke. Evaluating plaque elements for complexity on transesophageal echocardiogram can help stratify this risk of stroke. Either antiplatelets or anticoagulants can be used for stroke prevention.