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ImportanceApproximately 10% to 20% of large vessel occlusion (LVO) strokes involve tandem lesions (TLs), defined as concomitant intracranial LVO and stenosis or occlusion of the cervical internal carotid artery. Mechanical thrombectomy (MT) may benefit patients with TLs; however, optimal management and procedural strategy of the cervical lesion remain unclear.ObjectiveTo evaluate the association of carotid artery stenting (CAS) vs no stenting and medical management with functional and safety outcomes among patients with TL-LVOs.Design, Setting, and ParticipantsThis cross-sectional study included consecutive patients with acute anterior circulation TLs admitted across 17 stroke centers in the US and Spain between January 1, 2015, and December 31, 2020. Data analysis was performed from August 2021 to February 2022. Inclusion criteria were age of 18 years or older, endovascular therapy for intracranial occlusion, and presence of extracranial internal carotid artery stenosis (>50%) demonstrated on pre-MT computed tomography angiography, magnetic resonance angiography, or digital subtraction angiography.ExposuresPatients with TLs were divided into CAS vs nonstenting groups.Main Outcomes and MeasuresPrimary clinical and safety outcomes were 90-day functional independence measured by a modified Rankin Scale (mRS) score of 0 to 2 and symptomatic intracranial hemorrhage (sICH), respectively. Secondary outcomes were successful reperfusion (modified Thrombolysis in Cerebral Infarction score ≥2b), discharge mRS score, ordinal mRS score, and mortality at 90 days.ResultsOf 685 patients, 623 (mean [SD] age, 67 [12.2] years; 406 [65.2%] male) were included in the analysis, of whom 363 (58.4%) were in the CAS group and 260 (41.6%) were in the nonstenting group. The CAS group had a lower proportion of patients with atrial fibrillation (38 [10.6%] vs 49 [19.2%], P = .002), a higher proportion of preprocedural degree of cervical stenosis on digital subtraction angiography (90%-99%: 107 [32.2%] vs 42 [20.5%], P P = .003), a lower median (IQR) National Institutes of Health Stroke Scale score (15 [10-19] vs 17 [13-21], P P = .007), favorable shift in mRS scores (aOR, 1.46; 95% CI, 1.02-2.10; P = .04), and successful reperfusion (aOR, 1.70; 95% CI, 1.02-3.60; P = .002) were significantly higher for the CAS group compared with the nonstenting group. Both groups had similar odds of sICH (aOR, 0.90; 95% CI, 0.46-2.40; P = .87) and 90-day mortality (aOR, 0.78; 95% CI, 0.50-1.20; P = .27). No heterogeneity was noted for 90-day functional outcome and sICH in prespecified subgroups.Conclusions and RelevanceIn this multicenter, international cross-sectional study, CAS of the cervical lesion during MT was associated with improvement in functional outcomes and reperfusion rates without an increased risk of sICH and mortality in patients with TLs.

Background and PurposeWe aimed to describe the safety and efficacy of mechanical thrombectomy (MT) with or without intravenous thrombolysis (IVT) for patients with tandem lesions (TLs) and whether using intraprocedural antiplatelet therapy (APT) influences MT’s safety with IVT treatment.MethodsThis is a sub-analysis of a pooled, international multicenter cohort of patients with acute anterior circulation TLs treated with MT. Primary outcomes included symptomatic intracranial hemorrhage (sICH) and parenchymal hematoma type 2 (PH2). Additional outcomes included hemorrhagic transformation (HT), successful reperfusion (modified Thrombolysis in Cerebral Infarction [mTICI] 2b-3), complete reperfusion (mTICI 3), favorable functional outcome (90-day modified Rankin score [mRS] 0-2), excellent functional outcome (90-day mRS 0-1), in-hospital mortality, and 90-days mortality.ResultsOf 691 patients, 599 were included (255 underwent IVT+MT and 344 MT alone). There was no difference in the risk of sICH (aOR=1.43; 95%CI:0.72–2.87;p=0.308), PH2 (aOR=1.14; 95%CI:0.57– 2.28;p=0.705), and HT (aOR=0.92; 95%CI:0.54–1.57;p=0.751) between the IVT+MT and MT alone groups after adjusting for confounders. There was an IVT-by-intraprocedural APT interaction for sICH (pinteraction=0.031). Administration of IVT was associated with an increased risk of sICH in patients who received IV-APT (aOR=3.58; 95%CI:1.17–10.89;p=0.025). The IVT+MT group had higher odds of 90-days mRS 0-2 (aOR=1.76; 95%CI:1.05–2.94;p=0.030). The odds of successful reperfusion, complete reperfusion, 90-days mRS 0-1, in-hospital mortality, or 90-days mortality did not differ between the IVT+MT vs. MT alone groups.ConclusionOur study showed that the combination of IVT with MT for TL did not increase the overall risk of sICH, PH2, or overall HT independently of the cervical revascularization technique used. However, intraprocedural IV-ATP during acute stent implantation might be associated with an increased risk of sICH in patients who received IVT prior to MT. Importantly, IVT+MT treatment was associated with a higher rate of favorable functional outcome at 90 days.

BACKGROUND AND PURPOSE The effect of coronavirus disease 2019 (COVID‐19) pandemic on performance of neuroendovascular procedures has not been quantified. METHODS We performed an audit of performance of neuroendovascular procedures at 18 institutions (seven countries) for two periods; January‐April 2019 and 2020, to identify changes in various core procedures. We divided the region where the hospital was located based on the median value of total number of COVID‐19 cases per 100,00 population‐into high and low prevalent regions. RESULTS Between 2019 and 2020, there was a reduction in number of cerebral angiograms (30.9% reduction), mechanical thrombectomy (8% reduction), carotid artery stent placement for symptomatic (22.7% reduction) and asymptomatic (43.4% reduction) stenoses, intracranial angioplasty and/or stent placement (45% reduction), and endovascular treatment of unruptured intracranial aneurysms (44.6% reduction) and ruptured (22.9% reduction) and unruptured brain arteriovenous malformations (66.4% reduction). There was an increase in the treatment of ruptured intracranial aneurysms (10% increase) and other neuroendovascular procedures (34.9% increase). There was no relationship between procedural volume change and intuitional location in high or low COVID‐19 prevalent regions. The procedural volume reduction was mainly observed in March‐April 2020. CONCLUSIONS We provided an international multicenter view of changes in neuroendovascular practices to better understand the gaps in provision of care and identify individual procedures, which are susceptible to change.

Introduction: The Unruptured Intracranial Aneurysm Treatment Score (UIATS) weighs treatment versus observation risk, while the PHASES score estimates rupture risk. Certain clinical and radiographic features overlap between them whereas other features diverge. Thus management decisions may rely on conflicting information. Objective: We sought to determine the UIATS for known aneurysmal subarachnoid hemorrhage (aSAH) patients, as if the aneurysms been detected prior to rupture, and to correlate this with their PHASES scores. Methods: UIATS and PHASES scores were calculated for consecutive aSAH patients admitted to a regional stroke center between 1/2014 and 8/2018. A UIAT differential score was derived by subtracting the ‘observation’ from the ‘treatment’ score (a higher score favors treatment). Pro-treatment UIATS rates were calculated for the whole group and after excluding patients with non definitive scores of -3 to 3. These rates were also calculated for age-quartiles (/=67 years). The relationship of age and PHASES scores with UIATS was assessed using logistic regression. Results: Of 130 total patients, 121 (mean age 55 +/-15 years) had complete data, with median PHASES score of 5, concordant with their ultimate aSAH. Conversely, their median UIATS score was -1, and only in 54 (45%) did the score show balance (0) or favor treatment. Excluding those with UIATS -3 to 3, the number dropped to 18 (15%). Each unit increase in PHASES score was associated with 23% higher likelihood of pro-treatment UIATS (OR: 1.23, 95% CI: 1.05-1.44, p=0.009) indicating a degree of harmony. In contrast, although age>/=70 increases PHASES score, the odds of UIATS favoring treatment decreased by 5% with each year increase [OR: 0.95, 95% CI: 0.92-0.98, p=0.002]. When the four quartiles were analyzed, as age rose >58 years, the likelihood of pro-treatment UIATS fell (45-58 years, 63%; 59-66 years, 32%; >/=67 years, 0%). Results were comparable when analysis was repeated after excluding cases with UIATS - 3 -to 3. Discussion: UIATS and PHASES scores help guide management discussions, but clinicians should assume caution with those>58 years, as UIATS is more likely to fail these patients, who may still be at greater natural history risk of aneurysmal rupture.

Background: Most studies recruiting patients with acute ischemic stroke ascertain the final functional status at 3 months post symptom onset. The rates and predictors of late functional improvement (>3 months) in acute ischemic stroke patients has not been systemically studied. Methods: We analyzed data from three phase-III randomized multicenter clinical trials that recruited acute ischemic stroke patients within 3 or within 5 hours of symptoms onset. Late improvement was defined by an improvement of 1 or more grade in modified Rankin scale between ascertainments performed at 3 and 12 months post randomization. We analyzed the rates of late improvement in three groups of patients; patients treated with IV (recombinant tissue plasminogen activator [rt-PA], those treated with endovascular treatment, and those not treated with any acute reperfusion treatment. Multivariate analysis was performed to identify predictors’ of late functional improvement. Results: A total of 2555 patients (mean age ± SD; 66.4 ± 12.9 years) with acute ischemic stroke were analyzed.Late functional improvement was observed in 447 (17.5%, 95% confidence interval [CI] 15.9 to 19.2]) of 2555 patients analyzed. The rates of late functional improvement according to acute reperfusion treatment were as follows: 248 (22.4%) of 1106 in IV rt-PA treated; 108 (23.9%) of 452 in endovascular treated; and 91 (19.1%) of 477 in patients without any treatment (p= 0.179). In multivariate analysis, patients with age ≥65 years (odds ratio [OR], 0.53; 95 % CI 0.35 to 0.80; P = 0.002), and severity of baseline neurological deficits with National Institutes of Health Stroke Scale [NIHSS] score at 24 hours ≥ 20 (OR, 0.40; 95 % CI, 0.28 to 0.58; P = Conclusions: Late functional improvement occurs in one fourth of acute ischemic stroke patients and should be considered in estimation of functional recovery in future clinical studies.

Background: The endovascular management of acute extracranial carotid artery (EcCA) occlusion is unclear, as hypotension, a known phenomenon with carotid revascularization (CR), may exacerbate stroke symptoms. Most studiesinclude patients with tandem intracranial occlusions requiring thrombectomy, and even in those cases, there remains variability in regards to the order and manner of endovascular therapy (e.g. extra- vs intracranial revascularization first. Objective: We sought to compare the clinical and radiographic differences in EcCA patients who did or did not undergo proximal CR. Methods: We identified patients screened for possible intervention with acute EcCA occlusion from our prospective stroke database from 1/2014-8/2016and abstracted their demographic, clinical, and radiographic data. We compared differences between groups using chi-square analysis. Results: Thirty-four patients had EcCA: (10, 29% sole EcCA; 24, 71% tandem occlusions; these included 19 of our 143 (13%) patients undergoing acute stroke intervention (16 with tandem lesions, 3 without). Nine of the 16 tandem occlusion patients underwent specific CR, whereas in four we were unable to cross the EcCA, and in 3 only targeted the intracranial occlusion. The mean age was 69±14 years among 19 males and 15 females, with no intergroup differences. Most (19, 56%) received IV tPA in the whole group as well as the CR subset (7, 58%), who were loaded with antiplatelet agents afterwards; 11 underwent stent placement and 1 angioplasty alone. Although there were trends towards higher baseline and discharge National Institutes of Health Stroke scale scores (NIHSSS) among the CR group (19 vs 16 and 21 vs 18) and median discharge modified Rankin scales (5 vs 4), these were not significant (p>0.05). There were 5 deaths in both groups. As a comparison to the rest of our thrombectomy cohort, there was no significant difference in discharge NIHSSS (11 vs 13) among patients undergoing CR though there proportionately more deaths (25, 18%, no CRvs 5, 42%, CR, p Conclusion: These data suggest that EcCA patients should be informed of possible greater risk of mortality during acute stroke intervention. Further analyses may better identify practice standards to improve outcomes in this population.

Background: Early detection of acute stroke with large vessel occlusion (LVO) in both pre-hospital and emergency room settings results in favorable clinical outcomes. There is still no universal guideline for LVO screening. Method: We proposed that the presence of any of the following signs (Pomona scale): gaze deviation, expressive aphasia or neglect has a high sensitivity and accuracy to predict LVO. We reviewed a historical cohort of all acute stroke activation patients at Pomona Valley Hospital during February 2014 to January 2016. We tested Pomona scale in both groups. The predictive performance of Pomona scale was compared with different NIHSS cutoffs ( ≥4, ≥6, ≥8, ≥10), Los Angeles Motor Scale (LAMS), Cincinnati Prehospital Stroke Severity (CPSS) scale, Vision Aphasia and Neglect scale (VAN) and Prehospital Acute Stroke Severity (PASS) scale. Results: LVO was detected in 129 of the 777 acute stroke activation (17%). Two hundred and forty-two patients had nonLVO stroke (31%). NIHSS ≥4 and Pomona scale had highest sensitivity (0.99 and 0.98 respectively) to predict LVO. LAM scale had lowest sensitivity (0.68). Pomona scale had moderate accuracy (0.61) which was comparable with VAN (0.66) and PASS (0.67). NIHSS ≥4 had the least accuracy (0.28). When Pomona scale was combined with arm weakness, it had highest accuracy (0.77) and high sensitivity (0.92) to predict LVO in acute ischemic stroke subgroup. Using various NIHSS cut off to screen for LVO had lower accuracy than using other LVO screening tools. Conclusion: Pomona scale is very sensitive to predict LVO. It may be used as a screening tool for LVO in emergency room setting. Combination of arm weakness and Pomona scale may be used as a Pre-hospital LVO screening with moderately high accuracy.

To examine factors related to sensitivity of emergency medical services (EMS) stroke impression.We reviewed ambulance and hospital records of all patients transported to Long Island College Hospital between January 1, 2009 and January 1, 2011 by the hospital-based EMS with a discharge diagnosis of stroke or a confounding diagnosis, and compared EMS impression to hospital discharge diagnosis. We examined relationships between EMS diagnostic sensitivity and age, gender, ethnicity, NIH Stroke Scale (NIHSS), motor signs, aphasia, neglect, lesion side, circulation, stroke type, EMS provider level, and documented Cincinnati Pre-hospital Stroke Scale (CPSS) with contingency analysis and logistic regression.Stroke was validated in 18% (56/310) of patients and 50% (28/56) of these were missed by EMS. EMS diagnostic sensitivity was 50% (95% CI: 36-64%), and was related to NIHSS quartile (p = 0.014), with higher sensitivities in 2nd (69%; 95% CI: 44-86%) and 3rd (75%; 95% CI: 47-91%) vs. 1st (20%; 95% CI: 7-45%) and 4th (45%; 95% CI: 21-72%) quartiles, motor signs (62 vs. 14%, p = 0.002), and documented CPSS (84 vs. 32%, p = 0.0002). EMS impression was independently related to NIHSS quartile (1st vs. 2nd adjusted OR = 9.61, 1.13-122.03, p = 0.038) and CPSS (adjusted OR = 12.58, 2.22-111.06, p = 0.003).Stroke was missed more frequently when CPSS was not documented, in patients without motor signs, and in patients with moderate-severe stroke. The sensitivity of prehospital screening for patients with moderate-severe stroke might be improved by including additional non-motor signs and by stressing indications for when screens should be performed.

OBJECTIVE To evaluate the variability of determining eligibility for intravenous thrombolysis (IV t-PA) by a stroke team interpretation of computed tomographic (CT) scan of the head versus review of the radiology interpretation (presented in final report) in patients with acute ischemic stroke. METHODS We compiled a database of all IV t-PA-treated ischemic stroke patients at our academic institution based on the stroke team's CT scan interpretation. The CT scan reports of 171 patients were reviewed by an independent board-certified vascular neurologist who was blinded to clinical information except that all patients were being considered for IV t-PA to determine their eligibility for thrombolysis. The reviewer's responses were then compared with the treating team's decision to identify discrepancies, and the impact of the discrepant decisions on clinical outcome including 24-hour National Institute of Health stroke Scale (NIHSS) score and discharge modified Rankin scale (mRS), symptomatic hemorrhage (sICH), and asymptomatic hemorrhage (aICH). We compared the outcomes of patients who received IV t-PA despite cautionary neuroradiologist interpretation and placebo-treated patients from NINDS t-PA study. RESULTS The independent reviewer decided to treat with IV t-PA 123 patients (72%) after reviewing the radiology reports. The rate of NIHSS score improvement (52.0% vs. 62.5%, P = .22) was not different between patients in whom IV t-PA should or should not have been used based on radiology reports. Favorable clinical outcome defined by mRS of 0-2 at discharge (50.4% vs. 47.9%, P = .77) and in-hospital mortality (15.6% vs. 12.5%, P = .61) were similar between the 2 groups. Favorable outcome (discharge or day 7-10 mRS 0-2) was significantly higher in patients who received t-PA compared with placebo-treated patients (48% vs. 28%, P = .006). CONCLUSION Our study demonstrates that administering IV t-PA to patients based on the stroke team's interpretation of the CT scan versus review of the radiology interpretation does not lead to significant differences in clinical outcome, aICH, or sICH.

Background This study aims to develop a simple scale to identify patients with prehospital stroke with large vessel occlusion (LVO), without losing sensitivity for other stroke types. Methods The Emergency Medical Stroke Assessment (EMSA) was derived from the National Institutes of Health Stroke Scale (NIHSS) items and validated for prediction of LVO in a separate cohort. We compared the EMSA with the 3-item stroke scale (3I-SS), Cincinnati Prehospital Stroke Severity Scale (C-STAT), Rapid Arterial oCclusion Evaluation (RACE) scale, and Field Assessment Stroke Triage for Emergency Destination (FAST-ED) for prediction of LVO and stroke. We surveyed paramedics to assess ease of use and interpretation of scales. Results The combination of gaze preference, facial asymmetry, asymmetrical arm and leg drift, and abnormal speech or language yielded the EMSA. An EMSA less than 3, 75% sensitivity, and 50% specificity significantly reduced the likelihood of LVO (LR− = .489, 95% confidence interval .366-0.637) versus 3I-SS less than 4 (.866, .798-0.926). A normal EMSA, 93% sensitivity, and 47% specificity significantly reduced the likelihood of stroke (LR− = .142, .068-0.299) versus 3I-SS (.476, .330-0.688) and C-STAT (.858, .717-1.028). EMSA was rated easy to perform by 72% (13 of 18) of paramedics versus 67% (12 of 18) for FAST-ED and 6% (1 of 18) for RACE (χ2 = 27.25, P Conclusions The EMSA has superior abilities to identify LVO versus 3I-SS and stroke versus 3I-SS and C-STAT. The EMSA has similar ability to triage patients with stroke compared with the FAST-ED and RACE, but is simpler to perform and interpret.

Background: There is an urgent need to rapidly identify patients with acute ischemic stroke due to large vessel occlusion (LVO) to improve access to endovascular therapy. Aim: To derive a scale to improve pre-hospital detection of LVO. Methods: A retrospective review of consecutive patents enrolled in our prospective Comprehensive Stroke Center registry from 2008-2013 was conducted. Patients were excluded if they were < 18 yrs, not ambulatory, or did not have MRA or CTA. Demographic and clinical characteristics were compared between patients with and without LVO, defined as occlusion of the intracranial internal carotid artery, basilar artery, or middle cerebral artery. We compared a novel Large Vessel Occlusion Scale (LVOS) to the Cincinnati Prehospital Stroke Severity Scale (CPSSS) by constructing ROC curves and determining their area under the curve (AUC). Results: A total of 1,663 patients were identified (mean age = 62 yrs, SD = 14, 45.6% women and 66.8% Black). LVO was present in 171 patients (10.3%). The LVOS is a 6 point scale derived from the NIHSS that includes 2 points for abnormal speech or language (NIHSS ≥ 1 for either), 1 point for gaze preference (NIHSS ≥ 1), 1 point for facial asymmetry (NIHSS ≥ 1), 1 point for asymmetrical arm drift (RUE ≠ LUE), and 1 point for asymmetrical leg drift (RLE≠LLE). The LVOS had an AUC of 0.688 (95% CI 0.736 - 0.640), compared to 0.646 (95% CI 0.693 - 0.598) for the CPSSS and 0.678 (95% CI 0.0.723 - 0.633) for the NIHSS. A LVOS score ≥ 3 was 75.4% sensitive (95% CI 68.5 - 81.4) and 50.3% specific, positive likelihood ratio of 1.517 and negative likelihood ratio of 0.162 in predicting LVO. A CPSSS score ≥ 2 was 46.8% sensitive (95% CI 39.7 - 54.0) and 90.0% specific, positive likelihood ratio of 2.870 and negative likelihood ratio of 0.238 in predicting LVO. Conclusions: The LVOS compares favorably to the CPSSS in its ability to identify patients with LVO. Prospective prehospital validation is needed.

Background: Cerebrospinal fluid diversion may be necessary in the acute period after subarachnoid hemorrhage (SAH) if patients develop hydrocephalus. Though there is an opinion that certain ‘severe grade’ patients, e.g. Hunt and Hess (HH) grades 3-5, should have external ventricular drain (EVD) placement, regardless of hydrocephalus, there is no firm data, leaving the decision up to the judgement of the evaluating clinical team. Objective: We sought to measure changes in HH grades among grade 3-5 patients based on whether or not they had EVD placement. Methods: We prospectively collect demographic, clinical, and radiographic data on our SAH patients since January 2014. We selected HH grades 3-5 patients and compared admission and discharge HH grades among groups of patients who underwent EVD placement or surgical decompression within the first 24 hours and those who did not, using chi square test. Results: Among 54 total patients, there were 37 grades 3-5 patients (HH 3, n=26, 70.3%; HH 4, n=5, 13.5%; HH 5, n=6, 16.2%) in two groups: no EVD, n=22 (59.5%) and EVD, n=14 (37.8%, data unavailable for 1 patient). At discharge HH grades were: HH 1, n=10 (27%); HH 2, n=1 (2.7%); HH 3, n=10 (27%); HH 4, n=3 (8.1%); HH 5, n=1 (2.7%); dead, n=11 (29.7%); missing data, n=1. Mean age of 37 HH 3-5 patients was 58 years with no significant difference between the 2 groups. Hydrocephalus was seen in 11 of the 22 no EVD group and 13 of the 14 EVD group, p=0.007. Improvement in HH score between admission and discharge was seen in 10/14 EVD group, compared with 5/22 of the no EVD group, p=0.010. Worsening of HH score was found in 8/17 no EVD group (5 HH grade 5 patients excluded from this analysis), and 1 HH 4 patient (out of 14) in the EVD group, p=.014. Mortality occurred in 11/22 of the no EVD group (HH 3=5; HH 4-5=6) and 1/14 of the EVD group (HH 4, p=0.007). Conclusion: While the presence of hydrocephalus could potentially be a determinant in the decision to place EVDs among HH grades 3-5 patients, clinical change in patients who did not have an EVD placed occurred independently of hydrocephalus. Improvement of HH grade was more frequent, while its worsening was less common, among patients who underwent EVD or surgery within the first 24 hours. Mortality of HH grade 3 patients may also be impacted with EVD placement.

Background: Varicella zoster vasculopathy of the central nervous system (CNS-VZV) is rare. This topic has not been systemically analyzed in HIV patients. Method: We reviewed case reports/series in the literature from Pubmed using search term: varicella zoster, vasculopathy, stroke and HIV. Results: Forty-eight patients were identified. Eight patients (17%) had VZV vasculopathy after started on highly active antiretroviral therapy (HAART) consistent with central nervous system immune reconstitution inflammatory syndrome (CNS-IRIS). The average time from starting HAART to a neurological deficit was approximately 3 weeks. Rash occurred in ∼67%, with a mean 12 month interval from rash to CNS symptom onset though in 18 (64%) it occurred just prior to symptom onset. Patients had CNS lesions in the following distributions: posterior circulation, n=22 (46%); anterior circulation, n=13 (27%); and spinal, n=10 (21%). Specific abnormalities included stenosis/occlusion in 15 (83%), saccular aneurysm in 4 (22%), fusiform aneurysm in 2 (18%), and arterial wall enhancement in 2 (11%). The vasculopathy involved large vessels in 21/47 patients (45%), small arteries in 19 (40%), and both large and small arteries in 7 (15%). CSF pleocytosis was found in 30/36 patients (83%) (mean: 101), and CSF protein was elevated in 25/34 patients (74%). CSF immunological analysis was available in 29 patients. Twenty-five patient (89%) had either CSF positive for VZV DNA by PCR or anti-VZV IgG. 17/23 (74%) patients had VZV DNA positive in their CSF, and 13/21 (62%) had anti-VZV IgG antibody. Of the 35 patients with available treatment data, acyclovir was used as initial treatment in 27 (77%) with good recovery in 23 (85%). Thirteen cases received acyclovir with corticosteroids, and 11 had a good recovery (84%). Fourteen cases received acyclovir alone; 8 had a good recovery (57%). The mortality rate was 49%. VZV vasculopathy secondary from CNS-IRIS had better prognosis with a mortality rate 13%. Conclusion: Prompt treatment with acyclovir while waiting for CSF immunology is critical when CNS-VZV vasculopathy is a possibility. Rash, abnormal angiography or CSF pleocytosis give clues for diagnosis but not rule it out if negative. Steroid seems to improve the outcome of these patients.

Background: Contrast induced encephalopathy (CIE) following radiographic procedures, though a well-recognized complication, occurs sporadically enough that its diagnosis, prognosis, and treatment remain undefined and varied. Objective: We sought to identify clinical and radiographic criteria as well as treatment experience vis a vis reported outcomes. Methods: We identified case reports in PUBMED using search terms “contrast induced encephalopathy/neurotoxicity” from which we collected clinical and radiographic variables. Results: Among 52 reports (total 79 patients, including our own unpublished 3 cases) the mean age was 60±16 years, with similar gender distribution. Multiple different contrast media were used (mean dose, 207 ±158 mL). Onset was typically immediate, though delayed cases up to 39 days later occurred. There were 3 confirmed cases (n=2, direct evidence of contrast in cerebrospinal fluid; n=1, autopsy excluded other cause of abnormality) which we classified as ‘definite CIE’. No imaging hallmark features were described in 30 patients, whom we classified as ‘possible CIE.’ The remaining 47, ‘probable CIE,’ demonstrated either diffuse edema or enhancement, with the latter being a more common finding (enhancement=33, 42% vs 11, 14%). Administered treatments included: hydration (n=31), steroids (n=10), hyperosmolar agents (n=4), anti-hypertensives (n=3), anti-convulsants (n=3), thrombolytics (n=3), hemodialysis (n=2), hemicraniectomy (n=1), and n-acetylcysteine. (n=1). There was no correlation between imaging features nor treatment modality and final outcome. Resolution occurred within 5 ±9 days. While most patients improved, 9 (11%) had no/incomplete improvement including 2 (2.5%) who expired. The 2 fatal cases occurred among the only 2 children in the entire series, p Conclusion: The diagnostic approach to CIE may be systemized based on the identification of hallmark radiologic findings, which, whether present or absent, do not appear to affect outcome. Though hydration and supportive remedies are most common, other treatments were not associated with hastened or worsened symptom resolution. And while the outcome of CIE among adults is generally benign, it may be fatal in children.

Objective: To estimate the needed workforce of trained neurointerventionalists (NIs) to perform endovascular therapy (ET) for eligible patients with acute ischemic stroke (AIS). Method: Population and ischemic stroke incidence data were extracted with use of US Census and Centers for Disease Control and Prevention 2009 estimates. The annual “demand” is defined as the proportion of AIS patients who would meet inclusion criteria and clinical standards for ET. The “supply” is defined as the number of trained NIs and NIs in training. The “workforce” is the number of NIs needed to meet the demand (the number of eligible AIS patients) within an accessible geographic diameter. Data on NIs and NI fellowships were collected (Society of Neurointerventional Surgery [SNIS], Society of Vascular & Interventional Neurology [SVIN], Concentric Medical, and Penumbra Inc.). Results: The estimated number of NIs is close to 800, practicing within a 50-mile radius of major metropolitan areas in the United States, covering more than 95% of the US population. Approximately 40 NI fellows are graduating yearly from US training programs. In 5 years and 10 years, the number of NIs may reach 1,000 and 1,200, respectively. Currently, there are approximately 14,000 thrombectomy procedures performed in the United States each year. However, the percentage of AIS patients who may be eligible for ET in our estimation is 4% to 14%, or about 25,000 to 95,000 patients. This means that cases will occur at a rate of 26 to 97 per year in 5 years, or 22 to 81 per year in 10 years, for each NI. Providing 24/7 AIS coverage requires 2 to 3 NIs per medical center, adding to the challenge of providing manpower without diluting experience in areas of lower population density. Conclusion: The current and projected number of NIs would adequately supply the future need if the proportion of patients requiring AIS endovascular therapy increases. However, 2 to 3 NIs per comprehensive stroke center would be needed to provide 24/7 AIS therapy with a sufficient number of cases per NI. A tertiary stroke center model similar to the trauma model may provide the manpower solution without compromising the quality of care.

Background: Recanalization and angiographic reperfusion are key elements to successful endovascular and interventional acute ischemic stroke (AIS) therapy. Intravenous recombinant tissue plasminogen activator (rt-PA), the only established revascularization therapy approved by the US Food & Drug Administration for AIS, may be less effective for large artery occlusion. Thus, there is enthusiasm for endovascular revascularization therapies, which likely provide higher recanalization rates, and trials are ongoing to determine clinical efficacy and compare various methods. It is anticipated that clinical efficacy will be well correlated with revascularization of viable tissue in a timely manner. Method: Reporting, interpretation, and comparison of the various revascularization grading methods require agreement on measurement criteria, reproducibility, ease of use, and correlation with clinical outcome. These parameters were reviewed by performing a Medline literature search from 1965 to 2011. This review critically evaluates current revascularization grading systems. Results and Conclusion: The most commonly used revascularization grading methods in AIS interventional therapy trials are the thrombolysis in cerebral ischemia (TICI, pronounced “tissy”) and thrombolysis in myocardial ischemia (TIMI) scores. Until further technical and imaging advances can incorporate real-time reliable perfusion studies in the angio-suite to delineate regional perfusion more accurately, the TICI grading system is the best defined and most widely used scheme. Other grading systems may be used for research and correlation purposes. A new scale that combines primary site occlusion, lesion location, and perfusion should be explored in the future.

Background Computed tomographic angiography (CTA) has recently emerged as a non-invasive alternative to digital subtraction angiography (DSA) for the detection of residual cerebral aneurysms (RA). Objective To compare the diagnostic accuracy of CTA with the current ‘gold standard’, DSA, in the postoperative detection of RA. Methods Patient data from this single institution were prospectively gathered, and imaging results retrospectively blinded and analyzed. Between 2001 and 2005 eligible patients received microsurgical repair of cerebral aneurysms and were evaluated postoperatively by DSA and CTA. These single-institutional data were compiled with qualified studies published from 1997 to 2009, and a meta-analysis was performed. Results This institutional series reports sensitivity, specificity, positive (PPV) and negative predictive values (NPV) of 100%. Eleven studies met the inclusion criteria for the meta-analysis. A total of 427 patients with 513 aneurysms were included, with 61 RA detected by DSA and 40 detected by CTA. Unweighted analysis resulted in pooled sensitivity of 73.8%, specificity of 96.3%, PPV of 91.0% and NPV of 86.1%. Stratified analysis of studies using 16-slice CTA versus 2D DSA reported pooled sensitivity of 92.6%, specificity of 99.3%, PPV of 95.8%, and NPV of 97.8%. Conclusions This meta-analysis supports CTA as an acceptable modality for postoperative detection of RA, although DSA remains the gold standard. By implementing multidetector CTA technology in experienced centers, the sensitivity and specificity of CTA may approach that of traditional DSA for detecting RA. As a cost-effective, non-invasive modality, CTA is a promising alternative to DSA for initial and long-term evaluation of RA.

BACKGROUND AND PURPOSE We prospectively evaluated the safety of aggressive mechanical disruption of thrombus following full-dose intravenous (IV) recombinant tissue plasminogen activator (rt-PA) to treat ischemic stroke in 24 patients with an initial National Institutes of Health stroke scale (NIHSS) score of >or=10. METHODS Clinical evaluations were performed at presentation and 24 hours, 7 to 10 days, and 1 to 3 months (using modified Rankin scale) after treatment. These end points were compared to matched historical controls treated with IV rt-PA alone. RESULTS Of the 24 patients, mechanical disruption was undertaken in 17 patients with persistent angiographic occlusion using microcatheter exploration (n= 3), angioplasty (n= 5), snare maneuvers (n= 7), and combination of both (n= 2). Partial or complete recanalization was observed in 10 of the 17 patients. Neurological improvement at 24 hours (>or=4 point reduction in NIHSS score) was observed in 11 of 17 patients. Comparisons with matched controls suggest potential equivalence for symptomatic ICH (0% vs 12%), asymptomatic ICH (18% vs 15%), and early neurological improvement (65% vs 53%). CONCLUSION The study shows that aggressive mechanical thrombus disruption in large artery occlusion in the setting of acute ischemic stroke is safe with acceptable rates of ICH and promotes angiographic recanalization.

Introduction: Currently in the US, hospitals with Neuro-Interventional capabilities represent a small proportion of all acute care facilities, and most hospitals rely on regional transfers for these services. At the same time, it is known, that having to transfer patients for Neuro-interventional stroke therapy (NIST) decreases the rate of offering this therapy, because of the time lost in the transfer process. Objective: We sought to compare the rates of NIST being offered to patients after the inception of these services on-site, compared with the prior calendar year. Methods: All patients presenting with neurological disturbance within 4.5 hours with a National Institutes of Health Stroke score (NIHSSS) >/= 4 undergo emergent non contrast head computed tomography (CT) and CT angiography (CTA). All patients who have no contra-indications to systemic thrombolysis receive intravenous tissue plasminogen activator (IV tPA) and in addition, those with large vessel occlusion on CTA are offered NIST. Results: A total of 333 patients were admitted with the diagnosis of ischemic stroke (IS) in 2013. Of these 15 (4.3%) patients were transferred for NIST of which 9 received IV tPA and 6 did not. In addition, 2 patients were declined for NIST by regional centers and 2 who were transferred were unable to undergo NIST due to CT changes upon transfer. In the calendar year 2014 to date (8.5 months), among 225 IS patients, 21 (9.3%) were offered NIST, including 1 patient who was transferred from a neighboring facility. All patients offered treatment, underwent treatment. Among the 21 patients, 1 had spontaneous recanalization, another had a distal stenosis but no occlusion, and in 3, the target lesion could not be reached for intervention due to proximal carotid occlusion. Among these patients the mean initial NIHSSS was 20 and mean NIHSSS at discharge was 10. No patients experienced symptomatic hemorrhage, and one patient expired due to malignant ischemic swelling. Conclusion: Having on-site NI capabilities doubled our rate of offering NIST. Such data may factor into a hospital’s gap analysis as to its need for NIST. Further analysis is needed to assess whether our experience of significant decline in discharge NIHSSS corresponds to long-term good functional outcome.

BACKGROUND AND PURPOSE: Arterial reocclusion and distal embolization have been identified in previous studies of endovascular treatment in patients with acute ischemic stroke. We determined the rates of reocclusion and distal embolization during endovascular treatment using new generation stent retrievers. MATERIALS AND METHODS: Acute ischemic stroke patients underwent mechanical thrombectomy using new generation stent retrievers without intra-procedural heparin or proximal flow arrest for angiographically demonstrated arterial occlusion. "Distal embolization" was defined qualitatively as appearance of an occlusion on a downstream vessel. "Arterial reocclusion" was defined as subsequent reocclusion of the target vessel after initial recanalization had been achieved. The rates were compared with data from 4 previous prospective acute stroke protocols prior to availability of stent retrievers. RESULTS: The median initial National Institutes of Health Scale Score (NIHSS) for these patients was 14 (range 34-0); mean time from symptom onset to treatment was 5.2 +/- 2.6 hr. Arterial reocclusion occurred in 2.3% of these patients, whereas distal embolization occurred in 24% of the 86 patients. The rates of arterial reocclusion (3.0% versus 1.9%) and distal fragmentation (21.2% versus 30.8%) were similar in patients who did or did not receive IV alteplase prior to thrombectomy. Arterial reocclusion, but not distal embolization, was associated with a lower likelihood of favorable outcome at 1-3 months (P = .05; odds ratio, 3.9; 95% confidence interval, 0.01-0.98) after adjusting for age, initial NIHSS, sex, time to treatment, initial angiographic grade, symptomatic intracranial hemorrhage, and final recanalization. The rates of arterial reocclusion (2.1% versus 2.6% of 86 patients, p=0.8) and distal embolization (35.4% versus 18.4% of 86 patients, p=0.8) were not similar in patients treated with and without stent retrievers. CONCLUSIONS: Arterial reocclusion and distal embolization occur in 16%-18% of acute ischemic stroke patients undergoing mechanical thrombectomy with new stent retrievers without IV heparin or proximal flow arrest. The rates are no higher than those observed in cohorts treated without stent retrievers.

OBJECTIVE: To report the 1-month and intermediate-term results of treatment of symptomatic intracranial stenosis using drug-eluting stents. BACKGROUND: Patients with intracranial stenosis who are at high risk because of either high-grade stenosis or medication failure may have an annual risk of recurrent ischemic events in excess of 40%. Drug-eluting stents may reduce the rate of ischemic events in patients with a low restenosis rate. METHODS: We determined rates of technical success (defined as reduction of target lesion to stenosis

Carotid dissection is a less common but important cause of acute ischemic stroke, which has specific treatment implications.We describe the case of a patient with acute, fluctuating neurological symptoms found to be caused by carotid dissection who underwent endovascular stent-supported angioplasty of this lesion with good outcome.Pros and cons of the various treatment options encountered in this case including intravenous thrombolysis, angioplasty and stenting, and antithrombotic therapy are discussed.Endovascular treatment of carotid dissection in acute stroke can be performed safely. Treatment must ultimately be individualized to each specific case.

Myasthenia gravis (MG) is the most common disorder of the neuromuscular junction. Myasthenia crisis, defined as respiratory failure requiring mechanical ventilation in MG, is a common life-threatening complication that occurs in approximately 15% to 20% of patients with MG during their life time. The advent of effective mechanical ventilation, specialized neurointensive care units and the widespread use of immunotherapies have substantially altered the prognosis of myasthenic crisis. Early intubation and mechanical ventilation is perhaps the most important step in the management of myasthenic crisis. The authors favor an orotracheal approach for intubation, and placement of small bore duodenal tubes that may help decrease the risk of aspiration and may be more comfortable than regular nasogastric tubes for the patient. Plasma exchange may be more effective than the intravenous immunoglobulin in the treatment of myasthenic crisis involving respiratory failure. A randomized trial is required to confirm the superior efficacy of plasma exchange compared with intravenous immunoglobulin. In the acute setting, the role of immunosuppression and intravenous/intramuscular pyridostigmine and the newer agents such as tacrolimus remains limited and at times controversial. The therapy should be tailored at an individual basis using best clinical judgment.

Summary: Rapid advances in the field of interventional neurology and the development of minimally invasive techniques have resulted in a great expansion of potential therapeutic applications. We discuss therapeutic interventional neurology as applied in clinical practice in one of the two possible ways: 1) embolization leading to occlusion of blood vessels; and 2) revascularization leading to reopening of blood vessels. These procedures can be applied to a broad range of cerebrovascular diseases. In the first section of this review, we will explore the evolution of these interventions to occlude aneurysms, arteriovenous malformations, neurovascular tumors, and injuries. In the second section, revascularization in acute ischemic stroke, stenosis, and dural venous thrombosis will be discussed.

Background and Purpose— Phenytoin (PHT) is routinely used for seizure prophylaxis after subarachnoid hemorrhage (SAH), but may adversely affect neurologic and cognitive recovery. Methods— We studied 527 SAH patients and calculated a “PHT burden” for each by multiplying the average serum level of PHT by the time in days between the first and last measurements, up to a maximum of 14 days from ictus. Functional outcome at 14 days and 3 months was measured with the modified Rankin scale, with poor functional outcome defined as dependence or worse (modified Rankin Scale ≥4). We assessed cognitive outcomes at 14 days and 3 months with the telephone interview for cognitive status. Results— PHT burden was associated with poor functional outcome at 14 days (OR, 1.5 per quartile; 95% CI, 1.3 to 1.8; P P =0.09); the effect remained (OR, 1.6 per quartile; 95% CI, 1.2 to 2.1; P P =0.002) was associated with functional disability in a univariate model only. Higher quartiles of PHT burden were associated with worse telephone interview for cognitive status scores at hospital discharge ( P P =0.003). Conclusions— Among patients treated with PHT, burden of exposure to PHT predicts poor neurologic and cognitive outcome after SAH.

Subarachnoid hemorrhage is one of the most common entities encountered in neurocritical care units. Knowledge of disease sequelae and their management is paramount for all neurointensivists.This study relates the case of a 70-year-old woman with poor grade subarachnoid hemorrhage who underwent endovascular detachable coil embolization of a right internal carotid artery aneurysm. Her hospital course was subsequently complicated by symptomatic carotid stenosis and cerebral vasospasm requiring intervention.The discussants present their views regarding five main questions pertaining to management of the patient regarding the choice of endovascular versus surgical aneurysm occlusion, stent-supported angioplasty in a patient with a recent subarachnoid hemorrhage, and treatment options for vasospasm.

Introduction: Widespread use of intravenous tissue plasminogen activator (t-PA) for acute ischemic stroke is limited by multiple contraindications to its use. Case report: This article describes a patient with stuttering symptoms of pontine ischemia caused by vertebrobasilar dissection who suddenly deteriorated into a locked-in state 32 hours after symptom onset. The quadriparesis was successfully reversed within 3 hours of onset with the combination of pharmacologically induced hypertension, anticoagulation, and intravenous t-PA. Discussion: Even in the face of numerous contraindications (including hypertension, anti-coagulation, and treatment beyond 3 hours of symptom onset), intravenous t-PA can be used successfully in carefully selected cases.

To summarize new pathophysiologic insights and recent advances in the diagnosis and treatment of cerebral vasospasm after aneurysmal subarachnoid hemorrhage.Important, newly recognized mediators of cerebral arterial spasm after subarachnoid hemorrhage include superoxide free radicals, ferrous hemoglobin (which acts as a nitric oxide scavenger), endothelins, protein kinase C, and rho kinase. Microvascular dysfunction and autoregulatory failure also has been an area of increasing research focus in recent years. New diagnostic modalities include measures of cerebral blood flow such as single-photon emission computed tomography and perfusion computed tomography, magnetic resonance imaging, intracranial brain oxygen tension probes, and jugular venous oxygen saturation monitors. Proton magnetic resonance spectroscopy and microdialysis can detect tissue biochemical abnormalities, but these techniques have not found their way into routine clinical practice as of yet. In addition to nimodipine and hypertensive hypervolemic therapy, promising new treatments for vasospasm or its ischemic complications include magnesium sulfate, fasudil hydrochloride, tirilazad mesylate, erythropoietin, and induced hypothermia. Balloon angioplasty has emerged as the primary weapon for treating medically refractory ischemia from vasospasm and in many centers is being used as a first-line treatment or even prophylactically.The neurointensive care management of vasospasm after subarachnoid hemorrhage has evolved significantly over the past 10 years, with many new diagnostic modalities and promising treatments now available. Clinical trials are needed to evaluate the efficacy of these new techniques and to further define the optimal management of this often devastating complication.

ObjectiveTo describe the feasibility and safety of transradial access (TRA) in the interventional management of acute ischemic stroke (AIS).MethodsA retrospective review of the local institutional AIS interventional databases of three tertiary academic centers was performed and the use of TRA identified.ResultsTRA was attempted in 15 (1.5%) of 1001 patients; it was used in 12 cases due to transfemoral access (TFA) failure and in 3 as the primary strategy. The mean age was 72.3±8.6 and 46% were male. Baseline National Institutes of Health Stroke Scale score was 19.5±8.7, two patients (14%) received intravenous tissue plasminogen activator, and mean time from last known normal to intra-arterial therapy was 17.0±20.1 h. Five patients had anterior circulation occlusive disease and 10 had vertebrobasilar occlusions. TRA was effective in allowing clot engagement in 13 of 15 cases: one patient had a hypoplastic radial artery that precluded sheath advancement and one had chronic innominate artery occlusion that could not be crossed. Mean time to switch from TFA to TRA was 1.9±1.3 h and the mean time from radial puncture to reperfusion was 2.2±1.0 h. Modified Thrombolysis In Cerebral Infarction 2b–3 reperfusion via TRA was achieved in 9 of 15 patients (60%). No radial puncture site complications were noted. At 90 days, two patients (13%) had a good clinical outcome and seven (50%) had died.ConclusionsFailure of TFA in the endovascular treatment of AIS is uncommon but leads to unacceptable delays in reperfusion and poor outcomes. Standardization of benchmarks for access switch could serve as a guide for neurointerventionalists. TRA is a valid approach for the endovascular treatment of AIS.

Stroke center designation is an integral component of maintaining the systems of care for cerebrovascular diseases.1 Organization of hospitals into efficient vehicles of healthcare delivery helps improve clinical outcomes.2 The approval of IV tissue plasminogen activator (tPA) for acute ischemic stroke (AIS) highlighted the need for specialized stroke centers able to quickly mobilize all aspects of care to administer this treatment, due to its strict time window of administration.3 ,4 This led to primary stroke center (PSC) designation. Just as with cardiac ‘STEMI’ (ST segment elevation myocardial infarction) centers, which have increased performance of life saving percutaneous coronary intervention for acute myocardial infarction,5 ,6 PSCs have increased IV tPA utilization.2 ,7 Treatments for cerebrovascular conditions using specialized procedures, such as cerebral aneurysms, require yet additional galvanization of resources. Criteria proposed for PSCs do not specifically mandate neurointerventional availability,8 but the success of the PSC designation process extended itself to designation of comprehensive stroke centers (CSCs) which would possess these (and other) capabilities.9 ,10 A pathway for advanced accreditation of CSCs has been adopted by the Joint Commission (JC) for Hospital Accreditation.11 The current budgetary climate favors centralization of resources; directing care to specific designated stroke centers makes fiscal sense. Sequestering stroke patients in CSCs, which possess the necessary personnel and equipment to provide multimodal treatment, benefits the patient and also spares non-CSC facilities from disbursing these resources, which may be more limited, to patients for whom definitive care is ultimately lacking in their centers. Many hospitals find themselves de facto stroke centers, as forced closures of other neighboring institutions increase their own stroke admission volumes. These hospitals therefore bear responsibility to the communities they serve to fulfill the standards deserving of stroke center designation. Identifying centers able to …

BACKGROUND: The ‘Revascularization in Stroke Based on Clinical-Diffusion Mismatch’ study will evaluate the safety of endovascular therapy for stroke patients beyond 8 hours from onset. The inclusion criteria include diffusion weighted magnetic resonance imaging (DW-MRI) stroke lesion volume METHODS: CTs and DWI-MRIs of stroke and hemorrhage patients were screened to select a sample of lesions in the cerebral cortex, subcortex, basal ganglia, brainstem, and cerebellum for each group (CT hemorrhage, CT stroke, DW-MRI stroke). Three raters then measured lesion volume as follows: (AxBxC)/2, where A= largest linear lesion diameter in centimeters (cm) on a single slice; B=largest linear diameter perpendicular to A (cm); C=counts between lesion slices multiplied by slice thickness in cm. The ‘adjusted ABC/2’ formula for ICH weights each scan slice by proportion of hemorrhage to the index slice. To evaluate differences between these techniques, a single rater evaluated each lesion using each of the formulas. Measurements were examined through the intraclass correlation (ICC) statistic, to give a composite score of intra-observer and inter-observer variability. The ICC was tested for being significantly different from 0 yielding the reported p-value (1 indicates good ICC). RESULTS: CONCLUSION: The ABC/2 method has excellent ICC on DW-MRI and CT for different examiners, lesions, and locations as well as minimal variability between different formulas. This may be an alternative to computer planimetry for triage of stroke patients in future studies.

Background: ‘Clinical-diffusion mismatch’ (CDM) criteria may identify ischemic stroke (IS) patients with salvageable penumbra, and is intended for triage in a planned prospective trial of acute stroke intervention for patients presenting between 8 and 24 hours. For this study, CDM is defined as a National Institutes of Health Stroke Scale Score (NIHSSS) ≥8 and diffusion weighted imaging (DWI) stroke volume of ≤25 mL3 using a modified ‘ABC/2’ criteria, which has previously been validated against planimetric imaging and shown to have excellent inter-rater reliability. We sought to determine the percentage of potential patients who may be screened for enrollment on this basis in 2 urban teaching hospitals which each receive >200 stroke patients per year. Methods: We identified all IS admissions from our Get with the Guidelines database from 1/1/10-12/31/10. We then abstracted those arriving within 8 to 24 hours of symptom onset and then, of this subset, those who had an initial NIHSSS ≥8. To determine those meeting radiographic criteria, we measured stroke volume on the admission head computed tomogram (CT) using the unadjusted ABC/2 formula. As CT is known to have a 60% sensitivity for IS compared with DWI within 12 hours, we estimated that only 60% of the patients from the above calculation might still have lesion volumes ≤25mL3 on DWI. Results: A total of 588 IS patients were admitted in 2010. Of these, 162 patients presented within 8-24 hours. NIHSSS were ≥8 in 41 of whom 28 had lesions ≤25mL3. Considering 60% of these would remain valid on DWI, would leave approximately 17 patients (2.6%). Incomplete data led to attrition at each step; applying the same percentages at each recruitment step to those lost yields 9 patients, for an overall potential recruitment of 26 (4.4%, table). Conclusion: We conservatively estimate that in 1 year, 4% of IS patients within 8-24 hours demonstrate a CDM. These data are important for trialists and funding agencies planning studies using CDM criteria.

Background: The Joint Commission (JC) recently proposed criteria for certification of comprehensive stroke centers (CSCs), which have capabilities for stroke care in addition to those of primary stroke centers (PSCs). CSCs may be ideal facilities to care for patients ineligible for intravenous thrombolysis (IT). We sought to assess the availability of PSCs and CSCs and variability in their designation mechanisms in the United States (US). Methods: Numbers of designated stroke centers were determined from state Departments of Health (DOH) and JC listings and DOH surveys. These were integrated with 2010 US Census bureau data. Minimum hospital volumes for annual procedures and disease specific admissions required for CSCs (IT for 25 stroke patients, care of 20 subarachnoid hemorrhage patients, endovascular embolization of 15 cerebral aneurysms and surgical clipping of 10 aneurysms) were extracted per state from the 2009 Nationwide Inpatient Sample (NIS). Results: Projected number of CSCs are low (.28+/-0.54 per million capita). States with their own DOH based PSC designation had significantly higher numbers of all stroke centers per million capita (7+/-2 vs 3+/-2, p Conclusion: Projected numbers of CSCs are low. Hospital deficiencies must be investigated in order to meet the public’s needs. States with DOH designation mechanisms have higher numbers of all stroke centers, which administer thrombolysis at higher rates. More widespread adoption of these successful state policies may increase stroke centers’ ability to care for acute ischemic stroke.

The following two research questions were examined in this study: 1) What is the public's level of concern with ethics in science; and 2) Are religious affiliation, religious involvement, and education predictors of that concern in Asia? The sample includes 7,963 men and women between the ages of 20 and 59 from ten Asian countries. An overall low level of relative concern toward ethics in science was reported. Lower educational attainment was associated with lower odds of concern. Christian religious affiliation and moderate religious involvement were also associated with lower odds of concern. This article highlights the importance of more active research into social perspectives on ethics in science.