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BACKGROUND: Gait deficits and functional disability are persistent problems for many stroke survivors, even after standard neurorehabilitation. There is little quantified information regarding the trajectories of response to a long-dose, 12-month intervention. OBJECTIVE: We quantified treatment response to an intensive neurorehabilitation mobility and fitness program. METHODS: The 12-month neurorehabilitation program targeted impairments in balance, limb coordination, gait coordination, and functional mobility, for five chronic stroke survivors. We obtained measures of those variables every two months. RESULTS: We found statistically and clinically significant group improvement in measures of impairment and function. There was high variation across individuals in terms of the timing and the gains exhibited. CONCLUSIONS: Long-duration neurorehabilitation (12 months) for mobility/fitness produced clinically and/or statistically significant gains in impairment and function. There was unique pattern of change for each individual. Gains exhibited late in the treatment support a 12-month intervention. Some measures for some subjects did not reach a plateau at 12 months, justifying further investigation of a longer program (>12 months) of rehabilitation and/or maintenance care for stroke survivors.

BackgroundBoth stentriever and direct-aspiration thrombectomy effectively treat large-vessel occlusions. However, data are limited comparing clinical outcomes after aspiration-first versus stentriever-assisted aspiration for thrombectomy.MethodsA retrospective cohort study compared procedure times and radiographic outcomes after two mechanical thrombectomy techniques (aspiration first or stentriever). To minimize bias and variability inherent to multi-operator series, we assessed consecutive patients with cerebrovascular occlusions treated by a single surgeon during a 1 year period at two stroke centers. Expanded Thrombolysis in Cerebral Infarction (eTICI) grades were assessed by an investigator blinded to treatment.ResultsData from 93 patients (median age 70 years) were analyzed: 73 patients (78.5%) were treated with a strentriever-first strategy and 20 (21.5%) were treated with aspiration first, with stentriever rescue therapy required in only three of these cases following unsuccessful aspiration. There were no significant differences in patient demographics, sites of occlusion, or rates of tandem occlusions between aspiration-first and stentriever-assisted groups (p≥0.36). The rate of first-pass eTICI ≥2b was 75.0% (15/20) for aspiration-first and 52.1% (38/73) for strentriever-first groups (p=0.07), while the rate of final eTICI ≥2b was 100% (20/20) and 82.2% (60/72), respectively (p=0.04). The aspiration-first technique was associated with procedural times ≤25 min in a multivariable analysis (adjusted OR 4.77, 95% CI 1.15 to 18.39; p=0.03).ConclusionsIn this single-surgeon series, an aspiration-first technique was associated with a statistically significant improvement in eTICI outcomes and faster procedure times compared with stentriever-assisted aspiration. Further prospective studies are necessary to minimize selection bias inherent in this study design.

BACKGROUND AND PURPOSE: Intravenous thrombolysis (IVT) after stroke enhances C3a generation, which may abrogate the benefits of reperfusion. The C3aR antagonist SB290157 is neuroprotective following transient but not permanent middle cerebral artery occlusion (MCAo). SB290157 remains untested in thromboembolic (TE) models, which better approximate human stroke and also facilitate testing in combination with IVT. We hypothesized SB290157 would confer neuroprotection in TE stroke with and without “late” IVT. EXPERIMENTAL APPROACH: We used two different models of TE stroke to examine the efficacy of SB290157 alone and in combination with late IVT. We evaluated the benefit of SB290157 in attenuating post‐ischaemic behavioural deficits, infarction, brain oedema and haemorrhage. KEY RESULTS: Plasma C3a was elevated 6 hr after TE stroke alongside increased cerebrovascular C3aR expression, which was sustained to 4 weeks. Increased C3aR expression also was visualized in human ischaemic brain. In a photothrombotic (PT) stroke model, which exhibits rapid spontaneous reperfusion, SB290157 given at 1 hr post‐PT significantly improved neurofunction and reduced infarction at 48 hr. In an embolic (eMCAo) model, SB290157 administered at 2 hr improved histological and functional outcomes. Conversely, late IVT administered 4.5 hr post‐eMCAo was ineffective likely due to increased haemorrhage and brain oedema. However, SB290157 administered prior to late IVT ameliorated haemorrhage and oedema and improved outcomes. CONCLUSIONS AND IMPLICATIONS: We conclude that SB290157 is safe and effective with and without late IVT following TE stroke. Therefore, C3a receptor antagonist therapy represents a promising candidate for clinical translation in stroke, particularly as an adjuvant to IVT.

Background: Stroke is one of the leading causes of death and disability. Some aspects of inflammation are known to be detrimental and arresting these aspects may improve stroke outcomes. Neutrophils are critical neuroinflammatory mediators and among the first immune cells to respond to the onset of stroke. As the stroke evolves, neutrophils may expel their intracellular contents, referred to as Neutrophil Extracellular Traps (NETs), in a process called NETosis. NETs increase microvascular occlusion and lead to further progression of stroke. However, the interaction of NETs with the cerebral microvascular endothelial cells and the effect of this interaction on stroke outcomes is poorly understood. This project aims to investigate this relationship. Methods: Leukocytes and plasma from C57BL/6 wildtype mice were isolated from whole blood. The leukocytes were then plated in 24-well plates and divided into control and Oxygen Glucose Deprivation (OGD) simulating a stroke environment in vitro. Thereafter, leukocytes were subjected to immunofluorescent staining for neutrophils (Ly6G), and the NETosis markers citrullinated histones (CitH3) and dsDNA. Media from both groups was assayed for Neutrophil Elastase, IL-6, TNF-α, and lactate dehydrogenase (LDH). The remaining media was used to treat primary microvascular endothelial cells to assess inflammation and cell death. Results: Ly6G antibody staining verified that most of the leukocytes plated were neutrophils. The CitH3 and dsDNA immunostaining confirmed induction of NETosis in the OGD group. We also found a significant increase in IL-6 and LDH levels suggesting significant inflammation and cell death in OGD treated leukocytes. Exposure of endothelial cells with NETs enriched media obtained from OGD exposed leukocytes resulted in significant decrease in cell count and increase in IL-6 and LDH levels, suggesting that NETs promoted inflammation and death in the endothelial cells. Nuclear staining of the endothelial cells also exhibited significant decrease in cell count in cohorts treated with the OGD exposed leukocyte media. Conclusion: These pilot data suggest that NETosis may contribute to the cytotoxicity of cerebral endothelial cells during stroke and serve as a potential therapeutic target.

Introduction: Reperfusion resistance is one major challenge encountered during the thrombolytic treatment of acute ischemic stroke. Neutrophil extracellular traps formation (NETosis) facilitates thrombosis and contributes to reperfusion resistance. However, the plasma biomarker profile of NETs following stroke is poorly understood. Hypothesis: Understanding the precise evolution of NETosis biomarkers and their relationship with peripheral immune cells may provide new insight into the therapeutic options of acute ischemia stroke. Methods: Three-month-old C57BL/6 mice were subjected to middle cerebral artery occlusion for 60 minutes followed by reperfusion (Ischemia-Reperfusion, IR). Peripheral blood was collected on day 1, 2, 3, 5, and 7 after IR and whole blood cell counts were assessed. The concentrations of NETosis biomarkers [Citrullinated histone 3 (CitH3), Neutrophil Elastase (NE), Myeloperoxidase (MPO), and deoxyribonucleic acid (DNA)] in plasma were measured. Pearson correlation analysis was used to determine the relationship between the levels of NETosis biomarkers, blood cell counts and the ratios of neutrophils, lymphocytes, and platelets. Results: Compared to control (Ctrl) mice, the IR-subjected mice exhibited a drastic increase in plasma CitH3 and NE on day 1 (p Conclusions: There are time dependent changes in plasma NETosis biomarkers and their relationship with peripheral immune cells post-stroke may inform effectiveness of potential treatments to prevent the expansion of cerebral infarction and functional deterioration. However, further investigation is needed to confirm this hypothesis and its clinical implication.

Robust polyclonal humoral immune responses have the potential to generate a diverse set of antibodies to neutralize and eliminate viruses such as SARS-CoV-2 and protect against transmission, re-infection and the evolution of variants that evade immunity. CD73 is present on subsets of human B and T cells where it plays a role in lymphocyte activation and migration. CD73 also functions as an ectoenzyme that converts AMP into immunosuppressive adenosine. We have developed a humanized anti-CD73 antibody, mupadolimab (CPI-006), that blocks CD73 enzymatic activity and activates CD73POSB cells, thereby inducing differentiation into plasmablasts, immunoglobulin class switching, and antibody secretion independent of the adenosine modulatory activity. These effects suggest mupadolimab may enhance the magnitude, diversity, and duration of anti-viral responses in patients with COVID-19. This hypothesis was tested in a dose escalation phase 1 trial in 29 hospitalized patients with COVID-19. Single doses of 0.3 mg/kg – 5 mg/kg mupadolimab were well tolerated with no drug related adverse events. Doses greater than 0.3 mg/kg resulted in rapid generation of IgG and IgM to SARS-CoV-2 significantly above titers measured in convalescent controls, with elevated IgG titers sustained for more than 6 months beyond presentation of symptoms. Based on these findings, a randomized double-blind, placebo-controlled Phase 3 study in hospitalized patients was initiated. The primary endpoint was proportion of patients alive and free from respiratory failure within 28 days. This trial was discontinued early during the period of waning COVID-19 incidence after enrolling 40 patients. Although underpowered, results from this trial suggest improvement in the primary and key secondary endpoints in patients treated with single doses of 2 mg/kg and 1 mg/kg compared to placebo. The presumed mechanism of action, stimulation of B cells, may represent a novel approach to immunotherapy of COVID-19 and other viral infections.

Background Coronavirus disease 2019 (Covid-19) is associated with immune dysregulation and hyperinflammation, including elevated interleukin-6 levels. The use of tocilizumab, a monoclonal antibody against the interleukin-6 receptor, has resulted in better outcomes in patients with severe Covid-19 pneumonia in case reports and retrospective observational cohort studies. Data are needed from randomized, placebo-controlled trials. Methods In this phase 3 trial, we randomly assigned patients who were hospitalized with severe Covid-19 pneumonia in a 2:1 ratio receive a single intravenous infusion of tocilizumab (at a dose of 8 mg per kilogram of body weight) or placebo. Approximately one quarter of the participants received a second dose of tocilizumab or placebo 8 to 24 hours after the first dose. The primary outcome was clinical status at day 28 on an ordinal scale ranging from 1 (discharged or ready for discharge) to 7 (death) in the modified intention-to-treat population, which included all the patients who had received at least one dose of tocilizumab or placebo. Results Of the 452 patients who underwent randomization, 438 (294 in the tocilizumab group and 144 in the placebo group) were included in the primary and secondary analyses. The median value for clinical status on the ordinal scale at day 28 was 1.0 (95% confidence interval [CI], 1.0 to 1.0) in the tocilizumab group and 2.0 (non-ICU hospitalization without supplemental oxygen) (95% CI, 1.0 to 4.0) in the placebo group (between-group difference, -1.0; 95% CI, -2.5 to 0; P = 0.31 by the van Elteren test). In the safety population, serious adverse events occurred in 103 of 295 patients (34.9%) in the tocilizumab group and in 55 of 143 patients (38.5%) in the placebo group. Mortality at day 28 was 19.7% in the tocilizumab group and 19.4% in the placebo group (weighted difference, 0.3 percentage points (95% CI, -7.6 to 8.2; nominal P = 0.94). Conclusions In this randomized trial involving hospitalized patients with severe Covid-19 pneumonia, the use of tocilizumab did not result in significantly better clinical status or lower mortality than placebo at 28 days. (Funded by F. Hoffmann-La Roche and the Department of Health and Human Services; COVACTA ClinicalTrials.gov number, NCT04320615.).

Background: Chronic cerebral hypoperfusion (CCH) leads to vascular contributions to cognitive impairment and dementia (VCID). We and others have reported that either the genetic deficiency of complement C3a receptor (C3aR) or its pharmacological inhibition in rodents protect against cerebral ischemia. Hypothesis: CCH augments VCID via overactivation of C3aR in brain. Methods: Male C3aR knockout (C3aR -/- ) and wild-type (C3aR +/+ ) mice (Age:12 weeks; N=8-10/gp) were subjected to either VCID with bilateral common carotid artery stenosis (BCAS) or sham surgery. At 4-mo post-BCAS, changes in cerebral blood flow (CBF), hippocampal atrophy (HA), white matter degeneration (WMD) and ventricular size were determined with laser speckle contrast analysis and magnetic resonance imaging. Behavioral outcomes were evaluated using Morris water maze (MWM) and novel object recognition (NOR). Histopathology with Luxol-Fast Blue (LFB) staining, and protein biochemistry with Western blotting were also performed. Results: BCAS resulted in reduced CBF, inducing HA, WMD and ventricle enlargement in both groups compared to their sham controls. These deleterious findings were attenuated in C3aR -/- compared to C3aR +/+ mice. Moreover, the C3aR -/- -BCAS group performed significantly better than C3aR +/+ -BCAS group in MWM and NOR tests; however, mice subjected to BCAS never outperformed their sham-groups. WMD demonstrated by LFB-staining and reduced expression of myelin basic protein and tight junction proteins (ZO-1 and Occludin) in mice subjected to BCAS was mitigated in C3aR -/- as compared to C3aR +/+ mice. C3aR +/+ -BCAS also showed significantly higher expression of C3a in plasma and C3aR in brain lysates compared to their sham-controls. Conclusion: CCH augments C3aR activation leading to poor outcomes in VCID. Therefore, future studies in cell-specific mutant mice are warranted to understand the pathological role of C3aR in VCID.

Background: Stroke enhances endothelial C3a Receptor (C3aR End ) expression and humoral levels of C3a which is further exacerbated by intravenous thrombolysis (IVT). Therefore, it is critical to investigate the role of C3aR End in post-stroke neurovascular injury. Hypothesis: Genetic depletion of C3aR is vasculoprotective in stroke. Methods: Using a loxP - Cre approach (C3aR Flox/Flox xCdh5 Cre ), we generated mice conditionally deficient or sufficient in C3aR End (C3aR End-/- or C3aR End+/+ ), and subjected males (6±0.5-mo old) to thrombotic stroke (TS). Cerebral blood flow (CBF), behavioral outcomes, infarct volume, blood brain barrier (BBB) leakage, brain hemoglobin (Hb) content, brain tissue oxygen (PbtO 2 ) , neutrophil polarization ( Proinflammatory N1: Li6G + CD206 - vs. Antiinflammatory N2: Li6G + CD206 + ) and their brain infiltration were analyzed. P Results: TS resulted in similar degree of cerebral ischemia in both groups (N=10/gp); however, CBF, behavior, and infarct volume were significantly improved in C3aR End-/- vs. C3aR End+/+ mice at 72h post-TS. BBB-leakage and brain-Hb at 72h were less in C3aR End-/- vs. C3aR End+/+ mice but this did not meet significance (N=5/gp). Interestingly, C3a infusion 3h post-TS significantly enhanced BBB-leakage and brain-Hb in C3aR End+/+ but not in C3aR End-/- mice at 72h (N=5/gp), demonstrating that C3a in conjunction with C3aR End exacerbates neurovascular injury in TS. Moreover, late-IVT at 4h post-TS (2 mg/kgbwt; N=8/gp) significantly enhanced PbtO 2 in C3aR End-/- vs. C3aR End+/+ mice when assessed at 6h. Finally, C3aR deficiency significantly enhanced the N2/N1 ratio relative to the C3aR sufficient group at 24h post-TS (N=3/gp); thus inducing an anti-inflammatory effect and reduced neutrophil brain infiltration. Conclusion: C3aR End plays a critical role in stroke injury. Future studies targeting brain specific C3aR End are warranted.

Background: Intracerebroventricular (ICV) injection of angiotensin type 2 receptor (AT2R) agonists is neuroprotective in stroke. However, ICV delivery of a blood brain barrier impermeable AT2R agonists has limited utility in clinical stroke treatment. We investigated whether low dose endovascular (EV) delivery of a selective AT2R agonist, Compound 21 (C21), after stroke confers neuroprotection under various states of reperfusion. Methods: Aged male mice (12 mos) underwent either permanent middle cerebral artery ligation (pMCAL)(n=12) or spontaneously reperfusing embolic clot MCA occlusion (eMCAo)(n=10). Mice were randomized to EV-delivery of either C21 (1 μg/kg) or 10μL saline at the site of occlusion 2h post-stroke. Statistical significance was determined at p Results: C21 treatment following pMCAL prevented infarct progression and significantly reduced stroke injury by >30% at 48h post pMCAL (p25% (p Conclusions: We demonstrate that EV-delivery of C21 is effective in both non-reperfused and spontaneously reperfusing stroke. This site-specific delivery may have potential benefits as an adjuvant neuroprotectant combined with endovascular thrombectomy, while averting possible blood-pressure lowering risks associated with AT2R agonism. Of additional translational interest, the current COVID19 pandemic and related ongoing recombinant huACE2-trial therapies will eventually affect ATRs physiology. Given the prominence of thrombotic strokes in COVID19 patients, C21 as an AT2R agonist may be a potential therapy to test in COVID19-related thrombotic stroke models.

BACKGROUNDCOVID-19 is associated with immune dysregulation and hyperinflammation. Tocilizumab is an anti–interleukin-6 receptor antibody.METHODSPatients hospitalized with severe COVID-19 pneumonia receiving standard care were randomized (2:1) to double-blinded intravenous tocilizumab 8 mg/kg or placebo. The primary outcome measure was clinical status on a 7-category ordinal scale at day 28 (1, discharged/ready for discharge; 7, death).RESULTSOverall, 452 patients were randomized; the modified-intention-to-treat population included 294 tocilizumab-treated and 144 placebo-treated patients. Clinical status at day 28 was not statistically significantly improved for tocilizumab versus placebo (P=0.36). Median (95% CI) ordinal scale values at day 28: 1.0 (1.0 to 1.0) for tocilizumab and 2.0 (1.0 to 4.0) for placebo (odds ratio, 1.19 [0.81 to 1.76]). There was no difference in mortality at day 28 between tocilizumab (19.7%) and placebo (19.4%) (difference, 0.3% [95% CI, –7.6 to 8.2]; nominal P=0.94). Median time to hospital discharge was 8 days shorter with tocilizumab than placebo (20.0 and 28.0, respectively; nominal P=0.037; hazard ratio 1.35 [95% CI 1.02 to 1.79]). Median duration of ICU stay was 5.8 days shorter with tocilizumab than placebo (9.8 and 15.5, respectively; nominal P=0.045). In the safety population, serious adverse events occurred in 34.9% of 295 patients in the tocilizumab arm and 38.5% of 143 in the placebo arm.CONCLUSIONSIn this randomized placebo-controlled trial in hospitalized COVID-19 pneumonia patients, tocilizumab did not improve clinical status or mortality. Potential benefits in time to hospital discharge and duration of ICU stay are being investigated in ongoing clinical trials.Trial registrationClinicalTrials.gov NCTG432G615

Formation of neutrophil extracellular traps worsens cerebrovascular outcomes after traumatic brain injury., Traumatic brain injury (TBI) is a major cause of mortality and morbidity. Preventative measures reduce injury incidence and/or severity, yet one-third of hospitalized patients with TBI die from secondary pathological processes that develop during supervised care. Neutrophils, which orchestrate innate immune responses, worsen TBI outcomes via undefined mechanisms. We hypothesized that formation of neutrophil extracellular traps (NETs), a purported mechanism of microbial trapping, exacerbates acute neurological injury after TBI. NET formation coincided with cerebral hypoperfusion and tissue hypoxia after experimental TBI, while elevated circulating NETs correlated with reduced serum deoxyribonuclease-1 (DNase-I) activity in patients with TBI. Functionally, Toll-like receptor 4 (TLR4) and the downstream kinase peptidylarginine deiminase 4 (PAD4) mediated NET formation and cerebrovascular dysfunction after TBI. Last, recombinant human DNase-I degraded NETs and improved neurological function. Thus, therapeutically targeting NETs may provide a mechanistically innovative approach to improve TBI outcomes without the associated risks of global neutrophil depletion.

Purpose of review Surgical vascular intervention is an important tool in reducing the risk of stroke. This article examines the evidence for using the available options. Recent findings Carotid endarterectomy is an effective treatment option for reducing the risk of stroke in appropriately selected patients. Patients should be stratified for future stroke risk based on both the degree of stenosis and the presence of symptoms referable to the culprit lesion. Carotid stenting is also useful in reducing stroke risk, again in carefully selected patients. Because of the publication of significant data regarding both carotid endarterectomy and carotid artery stenting in the last several years, selection can be far more personalized and refined for individual patients based on demographics, sex, patient preference, and medical comorbidities. Routine extracranial-intracranial bypass surgery remains unproven as a therapeutic option for large vessel occlusion in reducing the incidence of ischemic stroke although some carefully screened patient populations remaining at high risk may benefit; procedural risks and pathology related to alterations in blood flow dynamics are challenges to overcome. Indirect revascularization remains an appropriate solution for carefully selected patients with cerebral large vessel steno-occlusive disease, and multiple variations of surgical technique are patient specific. Indirect revascularization may benefit from clinical trials with larger patient populations for validation in specific pathologies and offers the advantages of lower surgical complication rates and reduced risk of pathologic responses to altered cerebral flow dynamics. Summary Surgical solutions to reduce stroke risk provide important alternatives in appropriately selected patients and should be considered in addition to medical management and lifestyle modification for optimizing patient outcomes.

Background The development of novel broad-spectrum antibiotics, with efficacy against both gram-positive and gram-negative bacteria, has the potential to enhance treatment options for acute bacterial skin and skin structure infections (ABSSSIs). Ceftobiprole is an advanced-generation intravenous cephalosporin with broad in vitro activity against gram-positive (including methicillin-resistant Staphylococcus aureus) and gram-negative pathogens. Methods TARGET was a randomized, double-blind, active-controlled, parallel-group, multicenter, phase 3 noninferiority study that compared ceftobiprole with vancomycin plus aztreonam. The Food and Drug Administration-defined primary efficacy endpoint was early clinical response 48–72 hours after treatment initiation in the intent-to-treat (ITT) population and the European Medicines Agency-defined primary endpoint was investigator-assessed clinical success at the test-of-cure (TOC) visit. Noninferiority was defined as the lower limit of the 95% CI for the difference in success rates (ceftobiprole minus vancomycin/aztreonam) >−10%. Safety was assessed through adverse event and laboratory data collection. Results In total, 679 patients were randomized to ceftobiprole (n = 335) or vancomycin/aztreonam (n = 344). Early clinical success rates were 91.3% and 88.1% in the ceftobiprole and vancomycin/aztreonam groups, respectively, and noninferiority was demonstrated (adjusted difference: 3.3%; 95% CI: −1.2, 7.8). Investigator-assessed clinical success at the TOC visit was similar between the 2 groups, and noninferiority was demonstrated for both the ITT (90.1% vs 89.0%) and clinically evaluable (97.9% vs 95.2%) populations. Both treatment groups displayed similar microbiological success and safety profiles. Conclusions TARGET demonstrated that ceftobiprole is noninferior to vancomycin/aztreonam in the treatment of ABSSSIs, in terms of early clinical response and investigator-assessed clinical success at the TOC visit. Clinical Trials Registration NCT03137173., TARGET, a randomized, double-blind, active-controlled, multicenter, phase 3 study, demonstrated noninferiority of ceftobiprole to vancomycin/aztreonam in the treatment of acute bacterial skin and skin structure infections, in terms of early clinical response and investigator-assessed clinical success at the test-of-cure visit.

Objective: To study the potential role of Conivaptan on cerebral edema, infarct volume, neurological deficit and survival. Introduction: Although vasopressin has a significant detrimental role in stroke-related cerebral edema, the effect of mixed vasopressin antagonism in stroke has not been well studied. We studied the effects of conivaptan on the course of cerebral edema, severity of neurological deficit, infarct volume, aquaporin-4 (AQP4) protein levels and survival after experimental stroke. Methods: Animals were randomized to receive either conivaptan or vehicle after reperfusion of experimental middle cerebral artery occlusion. The severity of neurological deficit, edema, and infarct volume assessments were performed by an investigator blinded to group assignment. All assessments were performed at either 12h or 24h and Western blot was subsequently used to investigate AQP4 levels. Results: At 12h, conivaptan-treated mice (n=16) had 6.64±6.50% ipsilateral hemispheric enlargement compared to 16.55±7.05% in control mice (n=16, p=0.0003). Similarly, at 24h, conivaptan-treated mice (n=12) had 6.81±4.63% ipsilateral hemispheric enlargement in comparison to 13.93±5.43% in control mice (n=12, p=0.0023). At 24h, the conivaptan-treated mice had lower neurological deficits in comparison to control (p=0.04). There was no significant effect of conivaptan on infarct size or AQP4 levels in comparison to vehicle, naïve and sham group. Conclusions: The present study highlights the role of mixed vasopressin receptor antagonism in reducing cerebral edema secondary to brain ischemia. This data suggests the possibility of developing vasopressin antagonism as a new adjuvant in treatment of stroke-related brain edema.

Mutations in the potassium channel gene KCNC3 (Kv3.3) cause the autosomal dominant neurological disease, spinocerebellar ataxia 13 (SCA13). In this study, we expand the genotype-phenotype repertoire of SCA13 by describing the novel KCNC3 deletion p.Pro583_Pro585del highlighting the allelic heterogeneity observed in SCA13 patients. We characterize adult-onset, progressive clinical symptoms of two afflicted kindred and introduce the symptom of profound spasticity not previously associated with the SCA13 phenotype. We also present molecular and electrophysiological characterizations of the mutant protein in mammalian cell culture. Mechanistically, the p.Pro583_Pro585del protein showed normal membrane trafficking with an altered electrophysiological profile, including slower inactivation and decreased sensitivity to the inactivation-accelerating effects of the actin depolymerizer latrunculin B. Taken together, our results highlight the clinical importance of the intracellular C-terminal portion of Kv3.3 and its association with ion channel function.

Significant neuroprotective effects of angiotensin II type 2 (AT 2 ) receptor (AT 2 receptor) agonists in ischemic stroke have been previously demonstrated in multiple studies. However, the routes of agonist application used in these pre-clinical studies, direct intracerebroventricular (ICV) and systemic administration, are unsuitable for translation into humans; in the latter case because AT 2 receptor agonists are blood-brain barrier (BBB) impermeable. To circumvent this problem, in the current study we utilized the nose-to-brain (N2B) route of administration to bypass the BBB and deliver the selective AT 2 receptor agonist Compound 21 (C21) to näive rats or rats that had undergone endothelin 1 (ET-1)-induced ischemic stroke. The results obtained from the present study indicated that C21 applied N2B entered the cerebral cortex and striatum within 30 min in amounts that are therapeutically relevant (8.4-9 nM), regardless of whether BBB was intact or disintegrated. C21 was first applied N2B at 1.5 h after stroke indeed provided neuroprotection, as evidenced by a highly significant, 57% reduction in cerebral infarct size and significant improvements in Bederson and Garcia neurological scores. N2B-administered C21 did not affect blood pressure or heart rate. Thus, these data provide proof-of-principle for the idea that N2B application of an AT 2 receptor agonist can exert neuroprotective actions when administered following ischemic stroke. Since N2B delivery of other agents has been shown to be effective in certain human central nervous system diseases, the N2B application of AT 2 receptor agonists may become a viable mode of delivering these neuroprotective agents for human ischemic stroke patients.

Stroke-induced immune suppression predisposes the host to infections and can contribute to high morbidity and mortality in stroke patients. Because ischemic stroke has a profound effect on the systemic immune response, which may explain the increased susceptibility of stroke patients to infection, an urgent need persists for a better understanding of mechanisms associated with immune suppression; new and effective treatments for stroke can then be identified. NK cells play a key role in early host defense against pathogens by killing infected cells and/or producing cytokines such as IFN-γ. Because the phenotype and function of peripheral NK cells have been widely investigated in ischemic stroke, nCounter Inflammation Gene Array Analysis was used to build immune-related gene profiles of NK cells to comprehensively analyze the molecular signature of NK cells after ischemic brain injury. We observed distinct gene expression profiles reflecting different splenic NK-cell phenotypes and functional properties across the time course of transient middle cerebral artery occlusion (MCAO). Based on gene expression and pathway-network analysis, lower expression levels of signal transducer and activator of transcription-3 (STAT3) were observed in animals with MCAO compared with sham control animals. Genetic activation of STAT3 through the introduction of STAT3 clustered regularly interspaced short palindromic repeats (CRISPR) plasmid prevented the loss of NK-cell–derived IFN-γ production after MCAO, together with reduced bacterial burden and mortality. Our data suggest that brain ischemia impairs NK-cell–mediated immune defense in the periphery, at least in part through the JAK-STAT3 pathway, which can be readdressed by modulating STAT3 activation status.—Jin, W.-N., Ducruet, A. F., Liu, Q., Shi, S. X.-Y., Waters, M., Zou, M., Sheth, K. N., Gonzales, R., Shi, F.-D. Activation of JAK/STAT3 restores NK-cell function and improves immune defense after brain ischemia.

OBJECTIVES Although disparities in stroke care and outcomes have been well documented nationally, state-based registries to monitor acute stroke care in Florida (FL) and Puerto Rico (PR) have not been established. The FL-PR Collaboration to Reduce Stroke Disparities (CReSD) was developed to evaluate race-ethnicity and regional disparities in stroke care performance. The objective of this study was to assess and compare hospital characteristics within a large quality improvement registry to identify characteristics associated with better outcomes for acute ischemic stroke care. METHODS Trained personnel from 78 FL-PR CReSD hospitals (69 FL, 9 PR) completed a 50-item survey assessing institutional characteristics across seven domains: acute stroke care resource availability, emergency medical services integration, stroke center certification, data collection and use, quality improvement processes, FL-PR CReSD recruitment incentives, and hospital infrastructure. RESULTS The rate of survey completion was 100%. Differences were observed both within FL and between FL and PR. Years participating in Get With The Guidelines-Stroke (8.9 ± 2.6 years FL vs 4.8 ± 2.4 years PR, P < 0.0001) and proportion of hospitals with any stroke center certification (94.2% FL vs 11.1% PR, P < 0.0001) showed the largest variations. Smaller hospital size, fewer years in Get With The Guidelines-Stroke, and lack of stroke center designation and acute stroke care practice implementation may contribute to poorer outcomes. CONCLUSIONS Results from our survey indicated variability in hospital- and system-level characteristics in stroke care across hospitals in Florida and Puerto Rico. Identification of these variations, which may explain potential disparities, can help clinicians understand gaps in stroke care and outcomes and targeted interventions to reduce identified disparities can be implemented.

Objective Atrial fibrillation (AF) has a demonstrable effect on quality of life (QOL). Recurrent stroke occurs in 10% of patients with AF. The objective of this study was to demonstrate proof of concept that thoracoscopic pulmonary vein isolation and atrial appendage ligation (TPVIAL) could prevent recurrent stroke and could potentially improve QOL in patients with AF with a previous stroke. Methods The study was a National Institutes of Health-funded single-center proof-of-concept design that randomized 23 patients with AF-related stroke to TPVIAL (n = 12) or to medical management (n = 11). Quality of life was the primary outcome variable; secondary end points included restoration of rhythm, recurrent stroke, and surgical morbidity. Results Quality-of-life subscores at 3 and 6 months revealed improvements in energy and decreases in fatigue in the TPVIAL arm [baseline, 33 (19.8); 3 months, 49.5 (20.6), P = 0.01; 6 months, 55.5 (14.4), P = 0.03]. At 12-month follow-up, there were no recurrent strokes in the TPVIAL group. In the medically treated arm, two patients at 6 months (P = 0.22) and three total patients at 12 months (P = 0.09) had recurrent ischemic stroke. There was one death in the medical management arm. In the TPVIAL arm, no AF recurrence occurred in patients with paroxysmal AF, and one patient had recurrence of persistent and long-standing AF. Seven patients in the TPVIAL arm discontinued warfarin therapy for secondary stroke prevention. Conclusions This small proof-of-concept study showed that TPVIAL improved QOL on two subscores and restored normal sinus rhythm in all but one patient, and it showed the potential to prevent secondary stroke. A larger study will be needed.

Background and Purpose— Although aggressive medical therapy was superior to stenting in the SAMMPRIS trial (Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis), the stroke rate in the medical arm was still high. The aim of this study was to determine the association between hemodynamic markers (borderzone infarct pattern and impaired collateral flow on baseline imaging) and rates of recurrent stroke in patients treated medically in SAMMPRIS. Methods— This was a post hoc analysis of patients whose qualifying event for SAMMPRIS was an infarct in the territory of a stenotic middle cerebral artery or intracranial carotid artery. Infarcts were adjudicated as involving primarily internal or cortical borderzone territories, the core middle cerebral artery territory, or perforator territories, and collateral flow was assessed according to a standard scale (American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology). Log-rank tests and χ 2 tests were performed to assess associations of infarct patterns and collateral flow with rates of recurrent stroke. Results— Of 101 patients who qualified, 14 of 53 (26.4%) with borderzone infarcts, 2 of 24 (8.3%) with core middle cerebral artery infarcts, and 3 of 24 (12.5%) with perforator infarcts had a recurrent stroke in the territory ( P =0.14 for comparing the 3 groups, P =0.052 for borderzone versus nonborderzone). Of 82 patients with collateral flow assessment, 30 of 43 (70%) with borderzone infarcts, 7 of 19 (37%) with core middle cerebral artery infarcts, and 11 of 20 (55%) with perforator infarcts had impaired collateral flow distal to the stenosis ( P =0.049). Patients with borderzone infarcts and impaired collateral flow had the highest risk of recurrent stroke (37%). Conclusions— Borderzone infarcts and impaired collateral flow identify a subgroup of patients with intracranial stenosis who are at particularly high risk of recurrent stroke on medical treatment. Clinical Trial Registration— URL: https://www.clinicaltrials.gov . Unique identifier: NCT00576693.

Significant neuroprotective effects of angiotensin II type 2 (AT

Health care disparities exist between demographic groups with stroke. We examined whether patients of particular ethnicity or income levels experienced reduced access to or delays in receiving stroke care.We studied all admissions for ischemic stroke in the Nationwide Inpatient Sample (NIS) database between 2002 and 2008. We used statistical models to determine whether median income or race were associated with intravenous (i.v.) thrombolysis treatment, in-hospital mortality, discharge disposition, hospital charges, and LOS in high- or low-volume hospitals.There were a total of 477,474 patients with ischemic stroke: 10,781 (2.3%) received i.v. thrombolysis, and 380,400 (79.7%) were treated in high-volume hospitals. Race (P.0001) and median income (P.001) were significant predictors of receiving i.v. thrombolysis, and minorities and low-income patients were less likely to receive i.v. thrombolysis. Median income was a predictor of access to high-volume hospitals (P.0001), with wealthier patients more likely to be treated in high-volume hospitals, which had lower mortality rates (P = .0002). Patients in high-volume hospitals were 1.84 times more likely to receive i.v. thrombolysis (P.0001).African Americans, Hispanics, and low median income patients are less likely to receive i.v. thrombolysis for ischemic stroke. Low median income patients are less likely to be treated at high-volume hospitals. High-volume hospitals have lower mortality rates and a higher likelihood of treating patients with i.v. thrombolysis. There is evidence for an influence of socioeconomic status and racial disparity in the treatment of ischemic stroke.

Summary Background Early results of the Stenting and Aggressive Medical Management for Preventing Recurrent stroke in Intracranial Stenosis trial showed that, by 30 days, 33 (14·7%) of 224 patients in the stenting group and 13 (5·8%) of 227 patients in the medical group had died or had a stroke (percentages are product limit estimates), but provided insufficient data to establish whether stenting offered any longer-term benefit. Here we report the long-term outcome of patients in this trial. Methods We randomly assigned (1:1, stratified by centre with randomly permuted block sizes) 451 patients with recent transient ischaemic attack or stroke related to 70–99% stenosis of a major intracranial artery to aggressive medical management (antiplatelet therapy, intensive management of vascular risk factors, and a lifestyle-modification programme) or aggressive medical management plus stenting with the Wingspan stent. The primary endpoint was any of the following: stroke or death within 30 days after enrolment, ischaemic stroke in the territory of the qualifying artery beyond 30 days of enrolment, or stroke or death within 30 days after a revascularisation procedure of the qualifying lesion during follow-up. Primary endpoint analysis of between-group differences with log-rank test was by intention to treat. This study is registered with ClinicalTrials.gov, number NCT 00576693. Findings During a median follow-up of 32·4 months, 34 (15%) of 227 patients in the medical group and 52 (23%) of 224 patients in the stenting group had a primary endpoint event. The cumulative probability of the primary endpoints was smaller in the medical group versus the percutaneous transluminal angioplasty and stenting (PTAS) group (p=0·0252). Beyond 30 days, 21 (10%) of 210 patients in the medical group and 19 (10%) of 191 patients in the stenting group had a primary endpoint. The absolute differences in the primary endpoint rates between the two groups were 7·1% at year 1 (95% CI 0·2 to 13·8%; p=0·0428), 6·5% at year 2 (–0·5 to 13·5%; p=0·07) and 9·0% at year 3 (1·5 to 16·5%; p=0·0193). The occurrence of the following adverse events was higher in the PTAS group than in the medical group: any stroke (59 [26%] of 224 patients vs 42 [19%] of 227 patients; p=0·0468) and major haemorrhage (29 [13%]of 224 patients vs 10 [4%] of 227 patients; p=0·0009). Interpretation The early benefit of aggressive medical management over stenting with the Wingspan stent for high-risk patients with intracranial stenosis persists over extended follow-up. Our findings lend support to the use of aggressive medical management rather than PTAS with the Wingspan system in high-risk patients with atherosclerotic intracranial arterial stenosis. Funding National Institute of Neurological Disorders and Stroke (NINDS) and others.

Background and Purpose— Spontaneous swallowing frequency has been described as an index of dysphagia in various health conditions. This study evaluated the potential of spontaneous swallow frequency analysis as a screening protocol for dysphagia in acute stroke. Methods— In a cohort of 63 acute stroke cases, swallow frequency rates (swallows per minute [SPM]) were compared with stroke and swallow severity indices, age, time from stroke to assessment, and consciousness level. Mean differences in SPM were compared between patients with versus without clinically significant dysphagia. Receiver operating characteristic curve analysis was used to identify the optimal threshold in SPM, which was compared with a validated clinical dysphagia examination for identification of dysphagia cases. Time series analysis was used to identify the minimally adequate time period to complete spontaneous swallow frequency analysis. Results— SPM correlated significantly with stroke and swallow severity indices but not with age, time from stroke onset, or consciousness level. Patients with dysphagia demonstrated significantly lower SPM rates. SPM differed by dysphagia severity. Receiver operating characteristic curve analysis yielded a threshold of SPM≤0.40 that identified dysphagia (per the criterion referent) with 0.96 sensitivity, 0.68 specificity, and 0.96 negative predictive value. Time series analysis indicated that a 5- to 10-minute sampling window was sufficient to calculate spontaneous swallow frequency to identify dysphagia cases in acute stroke. Conclusions— Spontaneous swallowing frequency presents high potential to screen for dysphagia in acute stroke without the need for trained, available personnel.

Background and Purpose— Dysphagia can lead to pneumonia and subsequent death after acute stroke. However, no prospective study has demonstrated reduced pneumonia prevalence after implementation of a dysphagia screen. Methods— We performed a single-center prospective interrupted time series trial of a quality initiative to improve dysphagia screening. Subjects included all patients with ischemic or hemorrhagic stroke admitted to our institution over 42 months with a 31-month (n=1686) preintervention and an 11-month (n=648) postintervention period. The intervention consisted of a dysphagia protocol with a nurse-administered bedside dysphagia screen and a reflexive rapid clinical swallow evaluation by a speech pathologist. Results— The dysphagia initiative increased the percentage of patients with stroke screened from 39.3% to 74.2% ( P P P =0.0011). The best predictors of pneumonia were stroke type ( P P P =0.0037), and hospitalization before the beginning of the quality improvement initiative ( P =0.0449). Conclusions— A quality improvement initiative using a nurse-administered bedside screen with rapid bedside swallow evaluation by a speech pathologist improves screening compliance and correlates with decreased prevalence of pneumonia among patients with stroke.

The p.Arg420His allelic form of spinocerebellar ataxia type 13 has been reported in a large Filipino kindred, as well as three European index cases, one with an affected offspring. Haplotype analysis has confirmed independent mutational events. All individuals share adult-onset, predominantly cerebellar signs and a slowly progressive course. However, a comprehensive phenotypic description has yet to be published on SCA13p.Arg420His. In this study, we present the results of a detailed neurological clinical and diagnostic testing on 21 mutation-positive members of a four-generation Filipino family to further define this disease, aiding diagnosis and prognosis. Electronic supplementary material The online version of this article (doi:10.1007/s12311-013-0507-6) contains supplementary material, which is available to authorized users.

The autosomal dominant spinocerebellar ataxias (SCAs) are a diverse group of neurological disorders anchored by the phenotypes of motor incoordination and cerebellar atrophy. Disease heterogeneity is appreciated through varying comorbidities: dysarthria, dysphagia, oculomotor and/or retinal abnormalities, motor neuron pathology, epilepsy, cognitive impairment, autonomic dysfunction, and psychiatric manifestations. Our study focuses on SCA13, which is caused by several allelic variants in the voltage-gated potassium channel KCNC3 (Kv3.3). We detail the clinical phenotype of four SCA13 kindreds that confirm causation of the KCNC3R423H allele. The heralding features demonstrate congenital onset with non-progressive, neurodevelopmental cerebellar hypoplasia and lifetime improvement in motor and cognitive function that implicate compensatory neural mechanisms. Targeted expression of human KCNC3R423H in Drosophila triggers aberrant wing veins, maldeveloped eyes, and fused ommatidia consistent with the neurodevelopmental presentation of patients. Furthermore, human KCNC3R423H expression in mammalian cells results in altered glycosylation and aberrant retention of the channel in anterograde and/or endosomal vesicles. Confirmation of the absence of plasma membrane targeting was based on the loss of current conductance in cells expressing the mutant channel. Mechanistically, genetic studies in Drosophila, along with cellular and biophysical studies in mammalian systems, demonstrate the dominant negative effect exerted by the mutant on the wild-type (WT) protein, which explains dominant inheritance. We demonstrate that ocular co-expression of KCNC3R423H with Drosophila epidermal growth factor receptor (dEgfr) results in striking rescue of the eye phenotype, whereas KCNC3R423H expression in mammalian cells results in aberrant intracellular retention of human epidermal growth factor receptor (EGFR). Together, these results indicate that the neurodevelopmental consequences of KCNC3R423H may be mediated through indirect effects on EGFR signaling in the developing cerebellum. Our results therefore confirm the KCNC3R423H allele as causative for SCA13, through a dominant negative effect on KCNC3WT and links with EGFR that account for dominant inheritance, congenital onset, and disease pathology.

Levels of angiotensin converting enzyme 2 (ACE2), a cardio and neuro-protective carboxypeptidase, are dynamically altered after stroke in preclinical models. We sought to characterize the previously unexplored changes in serum ACE2 activity of stroke patients and the mechanism of these changes. Serum samples were obtained from patients during acute ischemic stroke ( n=39), conditions mimicking stroke (stroke-alert, n=23), or from control participants ( n=20). Enzyme activity levels were analyzed by fluorometric assay and correlated with clinical variables by regression analyses. Serum ACE2 activity was significantly lower in acute ischemic stroke as compared to both control and stroke-alert patients, followed by an increase to control levels at three days. Serum ACE2 activity significantly correlated with the presence of ischemic stroke after controlling for other factors ( P=0.01). Additional associations with ACE2 activity included a positive correlation with systolic blood pressure at presentation in stroke-alert ( R2=0.24, P=0.03), while stroke levels showed no correlation ( R2=0.01, P=0.50). ACE2 sheddase activity was unchanged between groups. These dynamic changes in serum ACE2 activity in stroke, which concur with preclinical studies, are not likely to be driven primarily by acute changes in blood pressure or sheddase activity. These findings provide new insight for developing therapies targeting this protective system in ischemic stroke.

Each of the thousands of rare neurological diseases requires a widely distributed network of centres, investigators and patients, so as to foster multidisciplinary investigations and involve sufficient numbers of patients in the discovery of disease pathogenesis and novel treatment. In this Review, we highlight the value of this collaborative approach in patient-oriented research into rare neurological channelopathies. Two networks, the Consortium for Clinical Investigations of Neurological Channelopathies (CINCH) and the Clinical Research Consortium for Studies of Cerebellar Ataxias (CRC-SCA), provide a link between patients with rare channelopathies and investigators who are studying disease pathogenesis and developing novel treatments. Interactions between patients, researchers and advocacy groups promote shared agendas that benefit patient education and recruitment, research collaboration and funding, and training and mentoring of junior investigators who are attracted to the study of the diseases that provide the focus for the two networks. Here, we discuss how linkage of national and international centres has enabled recruitment of study participants, provided opportunities for novel studies of pathogenesis, and facilitated successful clinical trials.

Background: Sex is a contributing factor to inequalities in stroke care. In line with the aims of the FL-PR CReSD Study to assess Get With The Guidelines-Stroke (GWTG-S) quality improvement data, we sought to compare stroke performance metrics by sex among 9 GWTG-S participating Puerto Rico hospitals from 2010-2014. Methods: Age and NIHSS-adjusted hierarchical generalized linear models, stratified by sex, were evaluated for the following GWTG-S performance metrics: IV tPA treatment, early antithrombotic therapy, DVT prophylaxis, antithrombotic therapy at discharge, anticoagulation therapy for atrial fibrillation (AF) at discharge, statin medication at discharge, smoking cessation counseling, defect-free care (compliance with all performance measures), in addition to CT scan ≤25 minutes and door-to-IV tPA administration ≤60 minutes of hospital arrival. Results: Among 3,277 acute ischemic stroke cases, 48% were women. As compared to men, women were older (72±14 vs. 68±13 years, P Conclusions: Overall, stroke care remains lower for Puerto Rican women than men. Continued adoption of the GWTG-S quality improvement program may help reduce sex disparities in quality of care across the island.

Background: It is unknown whether atrial fibrillation (AF) is responsible for increased morbidity and disability seen in women with ischemic stroke. We sought to determine whether patients with ischemic stroke and AF had poorer outcomes than ischemic stroke patients without AF and whether this effect is more pronounced among women. Methods: We analyzed data from the FL-PR CReSD Study, a large quality improvement registry of Florida (N=66) and Puerto Rico (N=9) hospitals based on the Get With The Guidelines-Stroke (GWTG-S) program. Discharge disposition was utilized as a surrogate marker for morbidity and disability, with discharge to home or rehabilitation in comparison to other discharge dispositions (skilled nursing facility, hospice or died). Multilevel generalized linear models were used to evaluate AF and sex disparities in discharge disposition adjusted for demographics, risk factors (hypertension, diabetes, heart failure, previous stroke/TIA), and NIHSS and CHADS2 scores. Results: We examined a total of 55,945 ischemic stroke patients, of whom 11,797 (21%) had AF at discharge. AF patients were older than non-AF patients (79.0±10.9 years vs. 68.7±14.4 years), had higher proportion of women (54% vs. 49%) and more severe strokes (mean NIHSS 10±9 vs. 7±7). Among AF patients, women were older (81±10 vs. 76±11 years) and had greater NIHSS (11±9 vs. 9±8) and CHADS2 scores (3.9±0.9 vs. 3.7±1.0) than men. Overall, AF patients were less likely discharged to home or rehabilitation than those without AF (54% vs. 71%, OR 0.93, 95% CI 0.89-0.98). There was a significant effect modification between AF and discharge disposition by sex. In stratified analyses by sex, AF was associated with less discharged to home or rehabilitation among women (OR 0.85, 95% CI 0.79-0.91), but not among men (OR 1.04, 95% CI 0.96-1.11). Conclusion: Women with AF were less likely discharged to home or rehabilitation facility after ischemic stroke. Baseline differences in age, stroke severity, risk factors, and comorbidities between men and women had little impact on the poorer outcome and discharge disposition after ischemic stroke in women. Further studies are warranted to identify the causes of sex-specific differences in stroke outcomes for patients with AF.

Background: Minor stroke/TIA is the most common cause for thrombolysis exclusion in patients acutely presenting to the hospital. Thrombolysis administration in this subgroup is highly variable amongst different clinicians and institutions. We aim to study the predictors of thrombolysis in patients with mild ischemic stroke in the FL-PR CReSD Study. Methods: 73,712 patients with ischemic stroke/TIA were prospectively enrolled from January 2010 to April 2015. We included 7,746 patients who had persistent neurological symptoms with NIHSS score ≤5 and arrived within 4 hours of symptom onset. Multilevel logistic regression analysis was used to identify independent predictors of thrombolysis in the subgroup of patients without contraindications to thrombolysis Results: 6,826 patients (25% final diagnosis TIA, 75% minor stroke) were included (mean age=70±14 years), 52.7% male, 70.3% white, 13% black, 16.7% Hispanic, median NIHSS=2 (IQR=1,4). Patients who received thrombolysis (N=1281, 18.7%) were younger (67 vs. 70.7 years, P Conclusion: Minor acutely presenting stroke patients were more likely to receive thrombolysis if they were young, white or Hispanic, and arrived early to the hospital with more severe neurological presentation specifically aphasia and altered level of consciousness. Identification of predictors of thrombolysis utilization is important in the design of educational programs and randomized trials to increase the use of thrombolysis for minor stroke.

Introduction: Abundant preclinical studies show efficacy for therapies targeted to the protective axis of the renin-angiotensin system in stroke. The expression and activity of angiotensin converting enzyme 2 (ACE2), a cardio and neuro-protective carboxypeptidase in this axis, have recently been shown to be dynamically altered during stroke in animal models. Hypothesis: The aim of this study was to characterize the previously unexplored changes in activity of ACE2, and other RAS enzymes, in the serum of patients experiencing acute ischemic stroke. Methods: Blood samples were obtained from patients with acute ischemic stroke (n=20) at presentation and again at three days post-stroke and enzyme activity levels in isolated serum were analyzed by fluorometric assay. These were compared to enzyme activity levels in samples obtained from a cohort of patients presenting with transient ischemic attack or other clinical presentations mimicking stroke and from healthy control participants (n=20). Results: Ischemic stroke resulted in significantly lower levels of serum ACE2 activity at an average of 3.5 hours after stroke as compared to both transient ischemic attack/stroke mimic and healthy control participant levels, followed three days later by an increase back to control levels. ACE activity was also significantly decreased following stroke, but without increases at three days. Renin enzyme activity during stroke did not significantly differ from controls at either time point. Serum ACE2 activity was negatively correlated with systolic blood pressure at presentation among stroke patients, while activity levels from a separate cohort of healthy young adults were positively correlated. Multiple regression analyses indicated that ACE2 activity levels were significantly correlated with a diagnosis of ischemic stroke, with those in the lowest tertile of all participants were at 7.7 times increased odds of having had a stroke. Conclusions: The characterization of the dynamic and novel changes in serum ACE2 activity in human stroke, which concur with preclinical studies, along with the demonstration of correlations with systolic blood pressure, provides new insight for the development of therapies that target this protective system in ischemic stroke.

Background and Purpose— Enrollment in the Stenting and Aggressive Medical Management for Preventing Recurrent stroke in Intracranial Stenosis (SAMMPRIS) trial was halted due to the high risk of stroke or death within 30 days of enrollment in the percutaneous transluminal angioplasty and stenting arm relative to the medical arm. This analysis focuses on the patient and procedural factors that may have been associated with periprocedural cerebrovascular events in the trial. Methods— Bivariate and multivariate analyses were performed to evaluate whether patient and procedural variables were associated with cerebral ischemic or hemorrhagic events occurring within 30 days of enrollment (termed periprocedural) in the percutaneous transluminal angioplasty and stenting arm. Results— Of 224 patients randomized to percutaneous transluminal angioplasty and stenting, 213 underwent angioplasty alone (n=5) or with stenting (n=208). Of these, 13 had hemorrhagic strokes (7 parenchymal, 6 subarachnoid), 19 had ischemic stroke, and 2 had cerebral infarcts with temporary signs within the periprocedural period. Ischemic events were categorized as perforator occlusions (13), embolic (4), mixed perforator and embolic (2), and delayed stent occlusion (2). Multivariate analyses showed that higher percent stenosis, lower modified Rankin score, and clopidogrel load associated with an activated clotting time above the target range were associated ( P ≤0.05) with hemorrhagic stroke. Nonsmoking, basilar artery stenosis, diabetes, and older age were associated ( P ≤0.05) with ischemic events. Conclusions— Periprocedural strokes in SAMMPRIS had multiple causes with the most common being perforator occlusion. Although risk factors for periprocedural strokes could be identified, excluding patients with these features from undergoing percutaneous transluminal angioplasty and stenting to lower the procedural risk would limit percutaneous transluminal angioplasty and stenting to a small subset of patients. Moreover, given the small number of events, the present data should be used for hypothesis generation rather than to guide patient selection in clinical practice. Clinical Trial Registration Information— URL: http://clinicaltrials.gov . Unique Identifier: NCT00576693.

Cardiac embolism, primarily from atrial fibrillation (AF), is implicated in a quarter of all ischemic strokes. In the setting of AF, contraindications to traditional therapies can create a clinical dilemma when choosing an agent for secondary stroke prophylaxis. Newer horizons in the medical and surgical management of AF have helped us choose from a wide variety of available therapies, the best possible management. In this article, we review the current trends in AF management including newer oral anticoagulants as well as surgical devices from a neurologist's view.

Enrollment was stopped after 451 patients underwent randomization, because the 30-day rate of stroke or death was 14.7% in the PTAS group (nonfatal stroke, 12.5%; fatal stroke, 2.2%) and 5.8% in the medical-management group (nonfatal stroke, 5.3%; non–stroke-related death, 0.4%) (P = 0.002). Beyond 30 days, stroke in the same territory occurred in 13 patients in each group. Currently, the mean duration of followup, which is ongoing, is 11.9 months. The probability of the occurrence of a primary end-point event over time differed significantly between the two treatment groups (P = 0.009), with 1-year rates of the primary end point of 20.0% in the PTAS group and 12.2% in the medical-management group. Conclusions In patients with intracranial arterial stenosis, aggressive medical management was superior to PTAS with the use of the Wingspan stent system, both because the risk of early stroke after PTAS was high and because the risk of stroke with aggressive medical therapy alone was lower than expected. (Funded by the National Institute of Neurological Disorders and Stroke and others; SAMMPRIS ClinicalTrials.gov number, NCT00576693.)

Stroke patients whose condition does not improve after intravenous administration of tissue plasminogen activator (tPA) may be candidates for endovascular intervention. Patients with new intracerebral hemorrhage noted during such interventions pose a difficult challenge to neurointerventionists and are often sequestered as treatment failures and deemed inappropriate for intraarterial recanalization efforts. The authors present a case in which aggressive intervention was performed despite evidence of contrast extravasation on preintervention angiography. This 37-year-old woman presented with an occlusion of the M1 segment of the left middle cerebral artery and a National Institutes of Health Stroke Scale score of 24. She received intravenous tPA without improvement. Angiography revealed M1 thrombus as well as active contrast extravasation without arterial displacement. Thromboaspiration was performed in light of her known hemorrhage with excellent recanalization. Immediate postprocedure imaging demonstrated a large insular hematoma and emergent craniectomy and hematoma evacuation were performed. At 4 months' follow-up, the patient was living at home, was ambulating, and had excellent comprehension with mild expressive aphasia. There is little peer-reviewed data in the literature to aid in the decision-making process when contrast extravasation is recognized at the time of preinterevention angiography. Continuation of mechanical endovascular stroke intervention, in light of active contrast extravasation, may be warranted in young patients with major deficits and absence of arterial displacement or delayed global filling. Further thrombolytics are not advised. In select stroke patients, continuation of a planned attempt at mechanical recanalization without the further use of thrombolytics may be warranted in light of known intracerebral hemorrhage.

Background and Purpose— A stroke “weekend effect” on mortality has been demonstrated in other countries with a possible slight effect in the United States. We studied patients with stroke in the Nationwide Inpatient Sample database for a weekend effect on thrombolytic use, in-hospital mortality, discharge disposition, hospital charges, and length of stay. Methods— The Nationwide Inpatient Sample 2002 to 2007 was searched for all emergency room admissions for International Classification of Diseases, 9th Revision codes corresponding to ischemic stroke. Generalized estimated equations for generalized linear models were performed, adjusting for gender, age, race, season, median income level, payer, comorbidity score, hospital region, hospital location, teaching status, bed size, and hospital annual stroke case volume to compare weekend versus weekday stroke admission incidence of thrombolytic use, in-hospital mortality, discharge disposition, hospital charges, and length of stay. The same analysis was performed using the International Classification of Diseases, 9th Revision codes for ischemic stroke AND transient cerebral ischemia to check internal validity for coding irregularities that may occur in differentiating stroke from transient ischemic attack. Results— There were 599 087 emergency room admissions for ischemic stroke: 159 906 weekend admissions and 439 181 weekday admissions. Generalized estimated equation for generalized linear model analysis was performed and demonstrated weekend compared with weekday patients with stroke were slightly more likely to receive thrombolytics (OR=1.114; 95% CI=1.039 to 1.194; P =0.003); incur slightly higher total hospital charges (effect ratio=1.011; 95% CI=1.006 to 1.017; P P Conclusions— There is a slight stroke weekend effect on thrombolytic use, total hospital charges, and length of stay, but no difference in in-hospital mortality or discharge disposition.

Background Treatment of intracranial atherosclerotic disease with the Wingspan-Gateway intracranial stent and balloon angioplasty system has been reported in several multicenter registries. To date, the incidence of acute intraprocedural thrombus formation during Wingspan stent placement has not been reported. Objective We reviewed the incidence of acute thrombus formation, treatment, and outcome for patients who underwent Wingspan stent placement by the senior author (B.L.H.) between June 2006 and April 2009. Methods We routinely perform angiograms every 10 minutes for at least 30 minutes after placement of a Wingspan stent to check for acute thrombus formation. Acute thrombus was graded: (1) visible thrombus but not flow limiting, (2) visible and flow-limiting thrombosis, and (3) complete stent occlusion. Recanalization was graded according to Thrombosis In Myocardial Infarction score. Results Forty-one patients underwent Wingspan stent placement for intracranial stenosis. Acute intraprocedural thrombus formation developed in 6 (14.6%) within 20 minutes after stent placement: 3 grade 1, 1 grade 2, and 2 grade 3. All 6 were successfully recanalized with Thrombosis In Myocardial Infarction score 3 after intravenous abciximab with or without intra-arterial tissue plasminogen activator and/or balloon angioplasty. There was no morbidity, and all 6 patients were discharged home at their neurological baseline. Conclusion We recommend serial angiography every 10 minutes for at least 30 minutes after placement of Wingspan stents. Once detected, acute thrombosis can be successfully treated with intravenous abciximab with or without intra-arterial tissue plasminogen activator and/or balloon angioplasty.

The Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) Trial showed that aggressive medical therapy was more effective than stenting for preventing stroke in patients with symptomatic intracranial stenosis. However, 15% of patients in the medical group still experienced a primary end point during a median follow-up of 32.7 months.To determine baseline features that were associated with a high rate of a primary end point in the medical arm of the SAMMPRIS Trial.A post hoc analysis of patients in the medical arm only of the SAMMPRIS trial. Enrollment occurred between October 2008 and April 2013 and included 227 patients randomized to medical management alone. Baseline demographic features, vascular risk factors, qualifying event, brain imaging, and angiographic features were analyzed. Bivariate and multivariable proportional hazard regression modeling was performed to relate baseline features to the time until a primary end point. The post hoc analysis was conducted from November 2014 to June 2015.The SAMMPRIS Trial compared stenting with aggressive medical management in patients with a stroke or transient ischemic attack attributed to 70% to 99% stenosis of a major intracranial artery.The primary outcome was any of the following: stroke or death within 30 days of enrollment, ischemic stroke in the territory of the symptomatic intracranial artery beyond 30 days after enrollment, or any stroke or death within 30 days after stenting a patient in the medical group during follow-up.A total of 227 patients were included in the study, 82 of whom were female, and the mean (SD) age was 59.5 (11.8) years. Being female (hazard ratio [HR], 1.9; 95% CI, 0.96-3.7), having diabetes mellitus (HR, 1.8; 95% CI, 0.9-3.5), not taking a statin at enrollment (HR, 2.6; 95% CI, 1.2-5.7), stroke as the qualifying event (HR, 2.5; 95% CI, 1.03-6.0), Rankin grade of 1 or greater (HR, 2.3; 95% CI, 0.9-5.5), old infarct in the territory of the stenotic artery (HR, 2.6; 95% CI, 1.3-5.1), and greater than 80% stenosis (HR, 1.9; 95% CI, 0.9-3.7) were associated (P.10) with higher risk on bivariate analysis. Factors that were significantly associated with a primary end point on multivariable analyses were old infarct in the territory (HR, 2.6; 95% CI, 1.3-5.3; P = .006), stroke as the qualifying event (HR, 3.0; 95% CI, 1.1-7.7; P = .03), and no statin use at enrollment (HR, 2.4; 95% CI, 1.1-5.2; P = .03).Old infarct in the territory of the stenosis, new stroke presentation, and absence of statin use at enrollment were independently associated with high rates of the primary end point in the medical group in the SAMMPRIS Trial. These features may be useful for selecting high-risk patients for future clinical trials evaluating alternative therapies for intracranial stenosis.clinicaltrials.gov Identifier: NCT00576693.

OBJECT Symptomatic intracranial atherosclerotic disease (ICAD) has a high risk of recurrent stroke. Genetic polymorphisms in CYP2C19 and CES1 are associated with adverse outcomes in cardiovascular patients, but have not been studied in ICAD. The authors studied CYP2C19 and CES1 single-nucleotide polymorphisms (SNPs) in symptomatic ICAD patients. METHODS Genotype testing for CYP2C19*2, *3, *8, *17 and CES1 G143E was performed on 188 adult symptomatic ICAD patients from 3 medical centers who were medically managed with clopidogrel and aspirin. Testing was performed prospectively at 1 center, and retrospectively from a DNA sample biorepository at 2 centers. Multiple logistic regression and Cox regression analysis were performed to assess the association of these SNPs with the primary endpoint, which was a composite of transient ischemic attack (TIA), stroke, myocardial infarction, or death within 12 months. RESULTS The primary endpoint occurred in 14.9% of the 188 cases. In multiple logistic regression analysis, the presence of the CYP2C19 loss of function (LOF) alleles *2, *3, and *8 in the medically managed patients was associated with lower odds of primary endpoint compared with wild-type homozygotes (odds ratio [OR] 0.13, 95% CI 0.03–0.62, p = 0.0101). Cox regression analysis demonstrated the CYP2C19 LOF carriers had a lower risk for the primary endpoint, with hazard ratio (HR) of 0.27 (95% CI 0.08–0.95), p = 0.041. A sensitivity analysis of a secondary composite endpoint of TIA, stroke, or death demonstrated a significant trend in multiple logistic regression analysis of CYP2C19 variants, with lower odds of secondary endpoint in patients carrying at least 1 LOF allele (*2, *3, *8) than in wild-type homozygotes (OR 0.27, 95% CI 0.06–1.16, p = 0.078). Cox regression analysis demonstrated that the carriers of CYP2C19 LOF alleles had a lower risk forthe secondary composite endpoint (HR 0.22, 95% CI 0.05–1.04, p = 0.056). CONCLUSIONS This is the first study examining genetic variants and their effects in symptomatic ICAD. Variant alleles of CYP2C19 (*2, *3, *8) were associated with lower odds of the primary and secondary composite endpoints. However, the direction of the association was opposite of what is expected based on this SNP. This may reflect an incomplete understanding of this genetic variation and its effect in symptomatic ICAD and warrants further investigations.

Introduction: The expression and activity of angiotensin converting enzyme 2 (ACE2), a cardio and neuro-protective carboxypeptidase, has recently been shown to be dynamically altered during and after stroke in animal models. Hypothesis: The aim of this study was to characterize the previously unexplored changes in activity of ACE2 in the serum of patients experiencing acute ischemic stroke. Methods: Serum samples were obtained from patients presenting with acute ischemic stroke (n=20) and again at three days post-stroke and enzyme activity levels were analyzed by fluorometric assay and compared to levels from non-stroke control patients (n=20). Results: Ischemic stroke resulted in a significant decrease in serum ACE2 at an average of 3.5 hours after stroke, which was followed by a rebound increase by three days later (Fig 1). ACE activity was also significantly decreased following stroke, but without rebound increases. Tumor necrosis factor-alpha converting enzyme activity was not significantly different from control. ACE2 activity was negatively correlated with systolic blood pressure (SBP) among stroke patients (Fig 2), while activity was positively correlated with SBP among a cohort of healthy young adults (n=16). Conclusions: The characterization of the dynamic and novel changes in serum ACE2 activity in human stroke, which follow observations from preclinical studies, along with the demonstration of a negative association with SBP, provides new insight for the development of therapies that target this protective system in the context of ischemic stroke. Data are mean ± SEM. RFU: relative fluorescence units; *p