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Mechanical thrombectomy is a procedure used for the treatment of acute ischemic stroke in patients with large vessel occlusions. Usually with a low complication rate, we present a case with a complication post‐thrombectomy not previously described in the literature noted on imaging as “blooming artifact”.

Background: Because acute treatment in stroke is time-based for inclusion, efficacy and safety, obtaining an accurate Last Known Normal (LKN) is of critical importance in stroke codes. We sought to assess with a larger sample if the assessment of 1st documented LKN times has improved since our prior 2013 data. Methods: Data was obtained from an IRB approved stroke registry in a single center from July 2013 to December 2018, for LKN time documented by a neurologist (“LKN2”). Chart review was done to document 1st reported LKN time as documented by EMS (or ED if no runsheets available) (“LKN1”). Inpatient stroke codes and hospital transfers were excluded. Differences in LKN1 and LKN2 were computed and stratified into Groups A (LKN1 is earlier in time than LKN2), B (LKN1 is the same as LKN2), and C (LKN1 is later in time than LKN2). Baseline characteristics, thrombolysis rates, stroke code time interval metrics, 90-day disability and death, discharge disposition, and symptomatic ICH rates, were compared between groups. Results: Of 990 stroke codes, 397 or 40.1% had agreeable LKN1 and LKN2 times (Group B) (increased from a historic 26.4%;p= Conclusion: Though initial LKN times obtained by EMS and ED responders have improved over time, there remains a significant discrepancy with 60% incorrect initial reports. Caution should be used when considering rt-PA treatments based on these LKN1 reports as 56% of cases could have been treated outside of current guidelines and evidence. This study highlights the need for continuous training in obtaining accurate LKN times and caution about using initial estimates of time.

Introduction: We recently published a risk prediction score for telestroke (TS) encounters to differentiate stroke mimics (SM) from ischemic cerebrovascular disease, derived and validated at multiple telestroke sites across the US and Europe. In this study, we assessed if it could be applied to a comprehensive stroke center, non-telemedicine, stroke code registry. Method: In this IRB approved analysis, we performed ROC curve analysis on retrospectively assessed prospectively collected data from acute stroke code registry database for patients from 10/2004 to 7/2018. We tested only characteristics previously shown to be associated with SM. The TM score = (Age multiplied by 0.2) + 6 (if Hx of atrial fib) + 3 (if Hx of HTN) + 9 (if facial weakness) + 5 (if NIHSS > 14) - 6 (if Hx of seizure)). Result: Based on final diagnosis, SM accounted for 1,978/4,185 (47.2%) of patients. Age, NIHSS > 14, facial weakness, atrial fibrillation, hypertension, and seizure were all significantly associated with diagnosis of SM. The TM Score performed well on ROC curve analysis with AUC of 0.704 (p Conclusion: This non-TS, face to face, validation cohort performed similarly to our validations at prior centers (0.70 vs 0.72). This finding not only continues to validate the TM score as an effective tool in assessing the ability to predict SMs, but also broadens its potential for use in non-TS populations. It is promising that it performed well despite a substantially higher proportion of SMs than in TS encounters where some may have already been screened out. Tools like the TM score may help highlight key clinical differences between mimics and stroke patients during complex, time-critical acute evaluations.

Introduction: There has been extensive education required as part of the Joint Commission (TJC) stroke center certification to rapidly identify acute stroke patients. One study found from 1998 to 2001, 25.3% of stroke codes (SC) were deemed stroke mimics (SM). The purpose of this study was to assess if SC activation in true stroke (TS) patients has improved as part of TJC certification. Methods: This study was a retrospective, observational study of prospectively collected data from an IRB approved Stroke Registry. This includes all SC managed by the stroke team from June 2006-June 2018. Data collected includes initial diagnosis, final diagnosis, demographics, and treatment variables. Analysis included all patients in the registry. Final diagnosis was adjudicated by stroke faculty. Baseline demographics, medical history, treatments, and baseline NIHSS were assessed. Data was examined for frequencies and distribution. Baseline demographics and correlations were compared as appropriate. Results: Of all SC (n=4602), 2100 were SM (45.6%). SM were associated with lower age and blood pressure, history of seizure or dementia, female sex, and black race (Table 1). SM also had a lower median NIHSS (3 vs 6, p Conclusions: In this large retrospective, study, 45.6% of SC activations were SM. This is a significant increase in the number of SM captured in previous studies. These results show healthcare professionals are overly cautious at alerting a stroke code as they do not want to miss an opportunity to provide thrombolytic treatment.

Introduction and Hypothesis: Intracranial Atherosclerotic Stenosis (ICAS) is associated with 8-10% of all strokes in the U.S. Although there is evidence in the Asian population that inflammation plays a role in ICAS, it has not been shown in the U.S. population. We hypothesized that midlife sensitivity C-reactive protein (hs-CRP), a marker of inflammation, is associated with late-life ICAS in the U.S. population. Methods: The Atherosclerosis Risk in Communities (ARIC) study recruited participants from four U.S. communities between 1987-1989. In the ancillary Dental ARIC study, dentate subjects from ARIC undergoing full-mouth examination also had blood samples obtained to measure the serum inflammatory marker, hs-CRP (1996-1998). High sensitivity ELISA assay that had been validated against nephelometry, was used to measure hs-CRP. Of this cohort, a subset (N=909) underwent high resolution 3T magnetic resonance angiogram at a follow-up visit (2011-2013). All images were analyzed in a centralized lab and ICAS was graded as no stenosis/3 mg/l), and ICAS. Results: A total of 909 subjects (mean age 62±6, 45% male, 81% Caucasian and 19% African-American), underwent assessment of hs-CRP and ICAS. Compared with the reference group (hs-CRP 50% ICAS, on univariate (Crude OR 1.3 95% CI: 0.9-2.0) or multivariable analysis (Adjusted OR 1.3, 95% CI: 0.9-2.0). Elevated hs-CRP (>3mg/l) was significantly associated with >50% ICAS in both univariate (Crude OR 1.6, 95% CI:1.1-2.3) and adjusted model (Adjusted OR 1.6, 95% CI:1.1-2.4). Conclusions: In this US population-based community study, we report a significant and independent association between inflammatory marker hs-CRP and ICAS. Further studies are required to test if anti-inflammatory drugs or diet prevents ICAS.

Goal: Significant proportions of stroke/transient ischemic attack events occur in patients taking daily aspirin. We studied the comparative effectiveness of Food and Drug Administration approved antiplatelet agents (aspirin, clopidogrel, and aspirin-dipyridamole combination) in prevention of recurrent vascular events in stroke/transient ischemic attack patients on aspirin.Materials and Methods: Consecutive patients having stroke or transient ischemic attack were screened and enrolled into this registry. Patients on long-term dual antiplatelet therapy or oral anticoagulants were excluded. Patient’s etiological stroke subtype, medication history, medication compliance, and Aspirin Platelet Function Test were assessed at baseline. Changes in antiplatelet regimen and statin therapy were also recorded. Follow up 6 and 12-month phone visits were conducted to assess primary outcomes of major adverse cardiovascular events that included a composite of death, myocardial infarction and stroke or transient ischemic attack.Result: One-hundred-eighty subjects (mean age ± SD= 68 ± 12 years, 59% male, 51% white, 49% African-American) were enrolled over 24-months. Majority (64%) had ischemic stroke (NIHSS: 0-21) and remaining (36%) had transient ischemic attack (ABCD2: 2-7). Within 12-months of the index cerebrovascular event, 3 (5.9%) participants on clopidogrel, 21 (18.8%) participants on aspirin and 7 (41.2%) participants on aspirin-dipyridamole combination had a composite vascular event (Log rank p=0.0011).Conclusion: This study shows a significant difference in major adverse cardiovascular event within 12 months of stroke/ transient ischemic attack on Aspirin, with effectiveness recorded in the order: clopidogrel>aspirin> aspirin-dipyridamole combination. A larger randomized pragmatic trial may help ascertain this finding and clarify if specific stroke subtypes benefit from specific antiplatelet agents.

Introduction: Stroke is a leading cause of adult disability that has long-term impact on outcome of patients. The current outcome measures are felt to be inadequate in measuring the impact of stroke in young patients (≤65) in midst of managing education, career, and family. Methods: This study assessed the reliability and discriminate validity of the young stroke questionnaire (YSQ). The development framework of the YSQ involved a two-step process. Initial feedback from stroke survivors and healthcare providers via multiple focus groups helped identify questions used to measure impact of stroke on 4 patient-centered domains: work and leisure, relationships, wellbeing, and healthcare resources. A subsequent focus group prioritized and refined items on the final YSQ. To determine the reliability and discriminate validity of YSQ, 25 young stroke survivors were consented at the Neurology Clinic. Standardized clinical assessments completed included the modified Rankin Scale (mRS), National Institutes of Health Stroke Scale (NIHSS), and the Stroke Impact Scale (SIS). Additionally, all patients were asked to complete the patient-centered questionnaire, YSQ. Results: Of 48 ischemic stroke patients screened, 25 (Mean age ± SD = 51 ± 9.2, 36% Males, 40% African-American, 56% White) patients qualified for enrollment into the young stroke questionnaire validation study. Using Levene’s test for equality of variance to compare YSQ and standardized clinical assessments, the YSQ was more likely to detect patient-centered disabilities post stroke in the following domains: relationships (α = 0.035) and healthcare resources (α = 0.027). Reliability of the summary measure was assessed using Cronbach’s alpha and found to be high (α = 0.903), indicating that the index created by summing the 4 dimensions is internally consistent and reproducible. Conclusions: Standardized clinical assessments are not sensitive to disabilities in young stroke survivors. When compared to standardized clinical assessments, the young stroke questionnaire is significantly capable of differentiating the young survivor perspective of the impact of stroke, specifically in area of relationships and healthcare resources.