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BACKGROUND AND PURPOSE This study was undertaken to develop a patient-centered stroke outcome measure and initial validation of the proposed Young Stroke Questionnaire (YSQ). METHODS This study assessed the reliability and discriminant validity of the YSQ. The initial questionnaire evolved from a focus group comprised of six young stroke survivors and six stroke neurologists centralized around four patient-centered domains. To determine the reliability and discriminant validity of the YSQ, 100 young stroke survivors were recruited and provided consent. Standardized clinical assessments completed included the modified Rankin Scale (mRS), National Institutes of Health Stroke Scale, and Stroke Impact Scale. Additionally, all patients were asked to complete the patient-centered YSQ. RESULTS Of the 100 enrolled patients in the study (mean age ± standard deviation = 49 ± 11.3, 58% females, 53% African American, 44% White), Cronbach alpha for all domains was >0.7. Moreover, Cronbach alpha for entire questionnaire was >0.9, indicating that the scale, with four subdomains, is internally consistent and reproducible. Discriminant validity of the scale was assessed by comparing the means of each subdomain of the YSQ among healthy subjects to the groups of stroke patients as defined by the mRS. The YSQ was able to differentiate subjects with good outcome (mRS = 0-1) from subjects with varying degree of disability as defined by the mRS (p = 0.026). CONCLUSIONS Standardized clinical assessments are not sensitive to disabilities in young stroke survivors. When compared to standardized clinical assessments, the YSQ is significantly capable of differentiating the young survivor perspective of the impact of stroke in all four subdomains.

Introduction: Prisma Health Tuomey (PHT) is a rural-based spoke hospital, with advanced Nurse Practitioners (ANP). Prisma Health Richland (PHR) is an urban-based hub hospital with access to vascular neurologists. In this ongoing project we evaluated the effectiveness of Zeriscope, a web-based, HIPAA compliant, teleproctoring platform, for ANP evaluation of etiology of ischemic stroke. Methods: PHT uses a web-based, HIPAA compliant, telemedicine platform, Zeriscope, to provide a live interactive video stream to PHR, a certified Comprehensive Stroke Center 45 miles away. Zeriscope uses a mobile exam headset, comprised of a camera attached to a cellphone and an audio headset, to provide two-way audio and visual communication between an APP and a board-certified vascular neurologist (Figure). The care was provided in inpatient setting with full access to neuroimaging, vascular imaging, cardiac imaging, and long-term monitoring. Patients evaluated directly by teleneurology platform in the PHT emergency room for TPA and thrombectomy were transferred to PHR and excluded from the teleproctoring assessment. Results: Fifty-two ischemic stroke and TIA patients (age 67.8 ± 12.7, 52 % African American, 69 % Males) were evaluated and treated in 4-month period from April to August 2021. Patients underwent a standardized stroke work-up to determine stroke etiology, which was classified by TOAST criteria (11.8% LAA, 19.6% Cardioembolic, 27.5% Lacunar, 39.2% Cryptogenic and 1.9% Undetermined). All patients received best medical management based on the secondary stroke prevention guidelines. To date, no patients experienced complications or were readmitted or needed transfer to a stroke center. Conclusion: Tele-proctoring is a feasible method of delivering stroke care that has not been previously implemented in a rural hospital. The use of Zeriscope was practical and effective in determination of ischemic stroke etiology and implementation of best practice guidelines.

Introduction Chronic periodontitis and atherosclerosis share common risk factors and produce the same inflammatory markers. Many studies found a high prevalence of chronic periodontitis in patients with atherosclerosis but there is no strong evidence to support a specific association of chronic periodontitis with cerebral atherosclerosis. We aimed to study the concurrent prevalence and association of chronic periodontitis with cerebral atherosclerosis and cerebrovascular diseases among the US population. Methods We performed a cross-sectional analysis of a Nationwide Inpatient Sample with adult hospitalizations to identify the primary diagnosis of cerebrovascular diseases [acute ischemic stroke (AIS), hemorrhagic stroke (HS), and transient ischemic attack (TIA)] with concurrent cerebral atherosclerosis and chronic periodontitis. Multivariate survey logistic regression models were fitted to evaluate the linkage of chronic periodontitis with cerebral atherosclerosis and cerebrovascular diseases. Results Of total 56,499,788 hospitalizations, 0.01% had chronic periodontitis. Prevalence of chronic periodontitis was higher in 50-64 years (36.18% vs. 23.91%), males (59.19% vs. 41.06% in females), Afro-Americans (25.93% vs. 15.21%), and 0-25th percentile median-household-income-category (38.31% vs. 30.15%) compared to non-chronic periodontitis. There was significantly higher prevalence of cerebral atherosclerosis (0.71% vs. 0.41%; p

Introduction: Stroke is a leading cause of disability affecting patients and their caregivers. Current outcome measures inadequately quantify the impact of stroke in young patients (≤65) in terms of managing education, career, and family. Methods: This study assessed the reliability and discriminate validity of the Young Stroke Questionnaire (YSQ) to further build upon the knowledge and understanding of young stroke patients and the specific needs for management and long-term outcomes relevant to young stroke survivors. The initial questionnaire evolved from a focus group comprised of 6 young stroke survivors and 6 stroke neurologists centralized around 4 patient-centered domains: work and leisure, relationships, wellbeing, and healthcare resources. To determine the reliability and discriminate validity of YSQ, 100 young stroke survivors were consented at the Neurology clinic. Standardized clinical assessments completed included the modified Rankin Scale (mRS). Additionally, all patients were asked to complete the patient-centered questionnaire, YSQ. Results: We enrolled 100 patients (Mean age ± SD = 49.2 ± 11.7, 42 Males, 53% African-American, 44% White) into the YSQ validation study. Cronbach’s α coefficients for the four domains and the total scale were calculated to measure the internal consistency of the YSQ. The α coefficients were found to be high (work & leisure α = 0.88, relationships α = 0.82, wellbeing α= 0.84, healthcare resources α= 0.75), indicating the scale with 4 subdomains is internally consistent and reproducible. The discriminant validity of the scale was assessed by comparing the means of each subdomain of YSQ among healthy subjects to the groups of stroke patients as defined by the mRS. YSQ was able to differentiate healthy subjects from subjects with varying degree of disability, as defined by the modified Rankin scale ( work and leisure p< 0.0001, relationships p< 0.0001, wellbeing p< 0.0001, Healthcare resources p= 0.017) Conclusions: Standardized clinical assessments are not sensitive to disabilities in young stroke survivors. When compared to standardized clinical assessments, the YSQ is significantly capable of differentiating the young survivor perspective of the impact of stroke in all the four subdomains.

Introduction: Periodontal disease (PD) is associated with incident and recurrent ischemic stroke. We investigated whether PD is associated with specific stroke subtype. Methods: In this cross-sectional study, PD was assessed in ischemic stroke and TIA patients. Moderate-severe PD was determined by full-mouth examination by a dentist. Clinical information including stroke etiological subtype (TOAST) was collected at admission. Based on vascular imaging, strokes caused by large-artery atherothrombosis were further analyzed to distinguish those caused by either intracranial atherosclerosis (ICAS) or extracranial atherosclerosis (ECAS). They were also classified as anterior or posterior circulation disease. Results: Consecutive patients (N=265) were enrolled (age 64 ± 12.8, 49% white, 46% black, 5% other and 56% male) between 2015-17. A third (N=87) were found to have PD. Twenty percent (N=42) of strokes were caused by large-artery atherothrombosis. In this group, there was a significantly higher proportion of patients with PD compared with those without PD (24% vs.12%, X 2 p=0.01). Patients with PD also had a significantly higher proportion (12% vs 5%) of stroke due to posterior circulation disease (crude OR 3.0, 95% CI 1.1-7.9, p=0.03), not anterior circulation disease (14% vs. 7%; crude OR 2.2, 95% CI 0.9-5.2, p=0.08). This association with posterior circulation disease persisted after adjustment for age, race, hypertension, diabetes, hyperlipidemia, smoking status, coronary artery disease, atrial fibrillation, and hemoglobin A1C (adjusted OR 3.1 95% CI 1.04-9.1, p=0.004). In addition, those with PD had a significantly higher rate of stroke due to ICAS compared to those without PD (20% vs. 8%; crude OR 2.6, 95% CI 1.3-5.6, p=0.01), while there was no significant difference between the groups for strokes due to ECAS (9% vs. 3%; crude OR 2.2, 95% CI 1.0-8.7, p=0.06). PD remained significantly associated with ICAS after adjustment for the same covariates (adjusted OR 2.6, 95% CI 1.1-5.8, p=0.004). Conclusion: We report a significantly higher proportion of stroke due to large-artery atherothrombosis in patients with PD compared to those without PD. We report an independent association between PD and ICAS, as well as posterior circulation disease.

Introduction: Craniocervical artery dissection (CeAD) is a leading cause of stroke in the young patient population. Recent studies reported a low rate of major adverse cardiac events (MACEs) in patients with CeAD, with no significant difference between patients randomized to anticoagulation or antiplatelet therapy. Objective: To compare the effectiveness of anticoagulation and antiplatelet therapy in patients with CeAD. Methods: All CeAD patients from 2015 to 2017 were consecutively identified by an electronic medical record-based application and enrolled in this prospective longitudinal registry. CeAD was confirmed by imaging and graded using the Denver scale for blunt cerebrovascular injury. Patients were followed for 12 months for MACE defined as stroke, transient ischemic attack (TIA), or death. Results: The cohort included 111 CeAD patients (age 53 ± 15.9 years, 56% Caucasian, 50% female). CeAD was detected by magnetic resonance (5%), computed tomography (88%), or catheter angiography (7%). CeAD was noted in the carotid (59%), vertebral (39%), and basilar (2%) arteries, 82% of which were extracranial dissections. CeAD was classified as grade I, II, III, and IV in 16, 33, 19, and 32%, respectively. A total of 40% of dissections were due to known trauma. A predisposing factor was noted in the majority (78%) of patients, including violent sneezing (21%), carrying a heavy load (19%), sports/recreational activity (11%), chiropractic manipulation (9%), abrupt/prolonged rotation of head (9%), and prolonged phone use (9%). At presentation, 41% had a stroke, 5% had TIA, 39% had headache, and 36% were asymptomatic. Favorable outcome defined as a modified Rankin Scale score of 0–2 was noted in 68% at 3 months and 71% at 12 months. The rate of MACEs at 3 and 12 months was 11 and 14%, respectively, with more events observed in patients who were not receiving anticoagulation/antiplatelet therapy due to contraindications (p = 0.008). Conclusions: We report diagnostic characteristics, as well as short- and long-term outcomes of CeAD. A high MACE rate was observed within the first 2 weeks of CeAD diagnosis, notably in patients not initiated on anticoagulation or antiplatelet therapy.

Introduction and Hypothesis: Approximately a third of stroke/TIA events occur in patients taking daily Aspirin. We studied the comparative effectiveness of FDA approved antiplatelet agents (Aspirin, Clopidogrel, and Aspirin-dipyridamole or ASA+DP) in prevention of recurrent vascular events in stroke/TIA patients on Aspirin. Methods: Consecutive patients identified as having stroke or TIA were screened and enrolled into this prospective longitudinal registry. Patients on dual antiplatelet therapy or oral anticoagulants were excluded. Patient’s etiological stroke subtype, medication history, medication compliance and Aspirin Platelet Function Test were assessed at baseline. Changes in antiplatelet regimen including Aspirin dose, Clopidogrel, ASA+DP, changes in statin therapy were recorded. Follow up 6 and 12 month phone visits were conducted to assess primary outcomes (stroke/TIA, MI, death), adjudicated by chart review. Results: A total of 183 subjects (mean age 68+12, 58% males, 50% white, 44% African-American) were enrolled over a 24 month period on Aspirin. Majority (63%) had ischemic stroke (NIHSS: 0-21) and remaining (37%) had TIA (ABCD 2 : 2-7). Ischemic strokes were attributed to penetrating artery disease (41%), large artery atherosclerosis (35%), other/undetermined (18%), and cardiogenic (6%). After 12-months, 4.9% of participants on Clopidogrel, 15.1% of participants on aspirin and 35.3% of participants on ASA+DP had a primary outcome (p=0.006), depicted in the Kaplan-Meier curve. Changes in Aspirin dose from 81mg to 325mg or statin therapy regimen did not appear to impact primary outcome. Conclusions: This study shows a significant difference in secondary vascular event within 12 months of stroke/TIA on Aspirin, with effectiveness recorded in the order: Clopidogrel>Aspirin>ASA+DP. A larger randomized pragmatic trial may help ascertain this finding and clarify if specific subtype benefit from specific antiplatelet agent. Figure

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

Viruses are a common cause of central nervous system (CNS) infections with many host, agent, and environmental factors influencing the expression of viral diseases. Viruses can be responsible for CNS disease through a variety of mechanisms including direct infection and replication within the CNS resulting in encephalitis, infection limited to the meninges, or immune-related processes such as acute disseminated encephalomyelitis. Common pathogens including herpes simplex virus, varicella zoster, and enterovirus are responsible for the greatest number of cases in immunocompetent hosts. Other herpes viruses (eg, cytomegalovirus, John Cunningham virus) are more common in immunocompromised hosts. Arboviruses such as Japanese encephalitis virus and Zika virus are important pathogens globally, but the prevalence varies significantly by geographic region and often season. Early diagnosis from radiographic evidence and molecular (eg, rapid) diagnostics is important for targeted therapy. Antivirals may be used effectively against some pathogens, although several viruses have no effective treatment. This article provides a review of epidemiology, diagnostics, and management of common viral pathogens in CNS disease.