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Purpose The aim of this tutorial is to provide speech-language pathologists with foundational knowledge of poststroke depression comorbidly occurring with aphasia. Given the negative effect of depression on functional outcomes and mortality, it is crucial that speech-language pathologists possess this knowledge in order to better advocate for and treat their patients. Method and Results Three areas of complementary expertise (speech-language pathology, psychology, and neurology) collaborated on this tutorial to address the following areas: (a) provide terminology associated with depression and related mood disorders, (b) describe the potential underlying pathophysiology of depression in the general population, (c) provide an overview of our existing understanding of comorbid poststroke depression and aphasia, and (d) summarize current assessment methods and interventions for poststroke depression in adults with aphasia. Conclusion Given the compounding impact aphasia and depression have on rehabilitation outcomes, it is imperative that speech-language pathologists understand terminology, assessment, and treatment practices for depression.

Recent stroke studies have shown that the ipsi-lesional thalamus longitudinally and significantly decreases after stroke in the acute and subacute stages. However, additional considerations in the chronic stages of stroke require exploration including time since stroke, gender, intracortical volume, aging, and lesion volume to better characterize thalamic differences after cortical infarct. This cross-sectional retrospective study quantified the ipsilesional and contralesional thalamus volume from 69 chronic stroke subjects’ anatomical MRI data (age 35–92) and related the thalamus volume to time since stroke, gender, intracortical volume, age, and lesion volume. The ipsi-lesional thalamus volume was significantly smaller than the contra-lesional thalamus volume (t(68) = 13.89, p

BackgroundFirst pass reperfusion (FPR) has been established as a key performance metric in mechanical thrombectomy (MT). The impact of FPR may be more relevant in fast progressors. We aim to study the impact of baseline Alberta Stroke Program Early CT Score (ASPECTS) on non-contrast CT and hypoperfusion intensity ratio (HIR) on CT perfusion on clinical outcomes after FPR.MethodsA prospective MT database was reviewed for patients with isolated occlusion of the intracranial internal carotid artery and/or middle cerebral artery M1 segment who underwent MT with complete reperfusion (modified Thrombolyis in Cerebral Infarction score 2c–3) from January 2012 to May 2019. The overall population was divided into ASPECTS >7 versus ≤7 and the subgroup of patients with baseline CT perfusion was divided into HIR ResultsA total of 436 patients were included in the analyses. FPR was achieved in 254 (58.3%) patients. ASPECTS modified the effect of FPR on clinical outcomes, with FPR predicting good outcomes in patients with ASPECTS ≤7 (46% vs 29%, adjusted OR 3.748; 95% CI 1.590 to 8.838, p=0.003) while no significant effect was detected in those with ASPECTS >7 (62.3% vs 53.1%, adjusted OR 1.372; 95% CI 0.798 to 2.358, p=0.25). Similarly, FPR predicted good outcomes in patients with HIR ≥0.3 (54.8% vs 41.9%, adjusted OR 2.204; 95% CI 1.148 to 4.233, p=0.01) but not in those with HIR ConclusionsThe impact of FPR on functional outcomes is highly dependent on baseline imaging characteristics, with a more prominent influence in patients presenting with lower ASPECTS and/or higher HIR.

ObjectiveThe primary objective of this study was to retrospectively investigate associations between clinical magnetic resonance imaging-based (MRI) metrics of corticospinal tract (CST) status and paretic upper extremity (PUE) motor recovery in patients that completed acute inpatient rehabilitation (AR) post-stroke.MethodsWe conducted a longitudinal chart review of patients post-stroke who received care in the Emory University Hospital system during acute hospitalization, AR, and outpatient therapy. We extracted demographic information, stroke characteristics, and longitudinal documentation of post-stroke motor function from institutional electronic medical records. Serial assessments of paretic shoulder abduction and finger extension were estimated (E-SAFE) and an estimated Action Research Arm Test (E-ARAT) score was used to quantify 3-month PUE motor function outcome. Clinically-diagnostic MRI were used to create lesion masks that were spatially normalized and overlaid onto a white matter tract atlas delineating CST contributions emanating from six cortical seed regions to obtain the percentage of CST lesion overlap. Metric associations were investigated with correlation and cluster analyses, Kruskal-Wallis tests, classification and regression tree analysis.ResultsThirty-four patients met study eligibility criteria. All CST overlap percentages were correlated with E-ARAT however, ventral premotor tract (PMv) overlap was the only tract that remained significantly correlated after multiple comparisons adjustment. Lesion overlap percentage in CST contributions from all seed regions was significantly different between outcome categories. Using MRI metrics alone, dorsal premotor (PMd) and PMv tracts classified recovery outcome category with 79.4% accuracy. When clinical and MRI metrics were combined, AR E-SAFE, patient age, and overall CST lesion overlap classified patients with 88.2% accuracy.ConclusionsStudy findings revealed clinical MRI-derived CST lesion overlap was associated with PUE motor outcome post-stroke and that cortical projections within the CST, particularly those emanating from non-M1 cortical areas, prominently ventral premotor (PMv) and dorsal premotor (PMd) cortices, distinguished between PUE outcome groups. Exploratory predictive models using clinical MRI metrics, either alone or in combination with clinical measures, were able to accurately identify recovery outcome category for the study cohort during both the acute and early subacute phases of post-stroke recovery. Prospective studies are recommended to determine the predictive utility of including clinical imaging-based biomarkers of white matter tract structural integrity in predictive models of post-stroke recovery.

Persons with mild stroke experience motor and cognitive impairments that negatively affect their health and quality of life. To address these deficits, it is essential for clinicians and researchers to precisely identify mild stroke survivors. Despite the fact that half of all strokes are categorized as mild, no standards exist on what constitutes a "mild" stroke. The purpose of this study is to summarize the current classification of mild stroke using a mapping review approach. Strategies to categorize "mild stroke" severity were explored in 188 papers indexed in the PubMed database. The results indicate that there was substantial variability in the procedures and scoring criteria used to determine mild stroke. To identify persons with mild stroke, researchers have largely applied assessment instruments developed to inform acute stroke care (eg, National Institutes of Health Stroke Scale, Modified Rankin Scale, Barthel Index). Unfortunately, these approaches demonstrate floor effects and fail to detect the long-term disabling impairments that often limit the outcomes of mild stroke survivors. Additional research is warranted to suggest an evidence-based mild stroke categorization strategy that enhances diagnosis, treatment, and referral decisions to the benefit of mild stroke survivors.

Introduction Stroke is the fifth leading cause of death in the United States. Tissue plasminogen activator and mechanical thrombectomy are the only effective treatments, but many patients are ineligible for these treatments. Objective The objective of this study was to determine whether an intravenous infusion of a non-HLA matched, unrelated donor umbilical cord blood (UCB) would improve functional outcomes. Methods We conducted a phase II multicenter, randomized (2:1), placebo controlled, double-blinded trial of UCB in adults with acute ischemic stroke. Patients had to have adequate immune function. Cord blood units were selected from U.S. public cord banks based on blood type, race, and cell dose. Study product was infused 3-10 days post stroke. Participants were randomized within strata of National Institutes of Health Stroke Scale Score (NIHSS) ( Results Seventy-nine participants were enrolled at 6 centers when the trial was closed early due to slow accrual related to COVID19; 73 participants (47 randomized to UCB) were included in the safety and efficacy analyses. The median (range) of the change in mRS was 1 (–2, 3) in UCB and 1 (–1, 4) in placebo. A shift analysis based on the proportional odds model showed an odds ratio of 0.9 (95% CI: 0.4, 2.3) after adjustment for baseline mRS and randomization strata. No differences were observed on the key secondary outcomes. There were 17 mild infusion reactions (27.6% UCB; 15.4% placebo). The distribution of serious and non-serious adverse events was similar between arms. Discussion This study demonstrated the safety of infusing non-HLA matched UCB to adults with acute ischemic stroke. Feasibility and logistics were challenging. The primary efficacy endpoint did not demonstrate benefit in this underpowered sample size. In a secondary ad hoc analysis, a trend of improved functional outcomes at day 90 in recipients of UCB more than 5 days post stroke (Figure 1) could be explored in future trials.

Background: Time to reperfusion remains one of the strongest predictors of outcome in large vessel occlusion strokes (LVOS). Herein, we aim to assess the impact of unfavorable vascular anatomy on mechanical thrombectomy (MT) number of passes and procedural times. Methods: Retrospectively review of a prospective MT database spanning January-July 2018 including acute LVOS involving the middle cerebral artery-M1 segment and available baseline CT angiography. The AIM2 score (Table 1) was applied with patients categorized as favorable (AIM2: 0-2) versus unfavorable (AIM2: >=3) anatomy. The primary outcome was the rate of Results: Patients with unfavorable anatomy (n=15) were significantly younger (52±19, p=0.02) and had lower rates of hypertension (46% vs 80%, p=0.01) and smoking (0% vs 39%, p Conclusions: The AIM2 score system represents a simple method for the systematically evaluation of vascular anatomy in MT and correlates significantly with increased number of MT passes.

Background and Purpose The first pass effect (FPE) is a key predictor of clinical outcome after mechanical thrombectomy (MT) for large vessel occlusion stroke (LVOS). We aim to study the impact of initial angiographic appearance of middle cerebral artery (MCA) occlusion on FPE. Methods A prospectively maintained MT database from January 2018 to December 2019 was reviewed. Patients with M1 segment MCA occlusion were included. FPE was defined as complete reperfusion (mTICI2c-3) after a single pass thrombectomy. Occlusion site angiographic appearance was classified into two categories; regular, when the occlusion is smooth stump with abrupt cut off and irregular which included all other types of occlusion. The primary outcomes were the rates of FPE and functional independence (90-day mRS 0–2). Uni- and multivariable analyses were performed to identify predictors of FPE. A secondary analysis was the interaction between the first line MT technique and the shape of occlusion on the FPE. Results A total of 319 were included in the analysis, the mean age was 65.1 years, 168 (52.7%) were females. Median [IQR] baseline NIHSS score was 17 [12–21] and ASPECTS was 8 [7–9]. Patients with the regular shape of occlusion had a significantly higher frequency of smoking (28.5% vs. 18.5%, p=0.037). Cardioembolic strokes were more frequently presented with the regular shape of occlusion (53.1% vs. 43.9%). Conversely, intracranial atherosclerosis was significantly associated with irregular shape of occlusion (13.2% vs. 6%), p=0.04. Irregular occlusion shape had significantly lower median number of MT passes to achieve successful reperfusion (1 [1–2] vs. 2 [1–3], p=0.01 and higher rates of FPE 46% vs. 34.6%, p=0.04) and a trend to lower rates of parenchymal hematoma type 2 (2.6% vs. 6.9%, p=0.067). There was no significant interaction between first-line MT technique and the shape of occlusion on FPE. Functional independence and 90-day mortality were similar between the two groups. On multivariable analysis, the irregular shape of occlusion was an independent predictor of FPE (OR 1.756; 95% CI[1.049–2.940], p=0.03). Conclusions The angiographic shape of M1 occlusion is a predictor of FPE. Large prospective multicenter studies are warranted for a better understanding of whether the occlusion appearance guides the selection of the MT techniques and hence potentially increase the chance of FPE. Disclosures M. Mohammaden: None. D. Haussen: 2; C; Stryker, Vesalio. 4; C; Viz.AI. L. Pisani: None. A. Al-Bayati: None. S. Belagaje: None. N. Bhatt: None. M. Frankel: None. R. Nogueira: 2; C; Phenox, Anaconda, Genentech, Brainomix, Viz-AI

Background and Purpose: Several reports have described lower mortality rates in overweight or obese patients as compared to normal weight ones. In the past decade, several studies have investigated the phenomenon, commonly known as the obesity paradox, with mixed results thus far. We sought to determine whether outcomes differ between patients with large vessel occlusion strokes (LVOS) after endovascular therapy (ET) according to their body mass index (BMI). Methods: We reviewed our prospectively collected endovascular database at a tertiary care academic institution. All patients that underwent ET for acute LVOS were categorized according to their BMI into 4 groups: (1) underweight (BMI < 18.5), (2) normal weight (BMI = 18.5–25), (3) overweight (BMI = 25–30), and (4) obese (BMI > 30). Baseline characteristics, procedural radiological as well as outcome parameters where compared. Results: A total of 926 patients qualified for the study, of which 20 (2.2%) were underweight, 253 (27.3%) had a normal weight, 315 (34%) were overweight, and 338 (36.5%) were obese. When compared with normal weight (reference), overweight patients were younger, had higher rates of dyslipidemia and diabetes and higher glucose levels, while obese patients were younger, less often smokers, and had higher rates of hypertension and diabetes and higher glucose levels. Other baseline and procedural characteristics were comparable. The rates of successful reperfusion (modified treatment in cerebral ischemia, 2b–3), parenchymal hematomas, 90-day good clinical outcomes (modified Rankin scale, 0–2), and 90-day mortality were comparable between groups. On multivariate analysis, BMI was not associated with good outcomes nor mortality. Conclusion: In patients treated with mechanical thrombectomy, BMI is not associated with outcomes. However, patients who are overweight or obese have more comorbidities and a higher stroke risk and, thus, should strive for a normal weight.

Background and Purpose— Endovascular therapy is the standard of care for the treatment of proximal large vessel occlusion strokes. Its safety and efficacy in the treatment of distal intracranial occlusions has not been well studied. Methods— The data that support the findings of this study are available from the corresponding author on reasonable request. Retrospective review of a prospectively collected endovascular database (2010–2015, n=949) for all patients with distal intracranial occlusions treated endovascularly. Distal occlusions were defined as any segment of the anterior cerebral artery (ACA), posterior cerebral artery, or occlusion at or distal to the middle cerebral artery (MCA)-M3 opercular segment. Results— Distal occlusions were treated in 69 patients. The mean age was 66.7±15.8 and 57% were male. Patients (29 [42%]) received intravenous tPA (tissue-type plasminogen activator). The median preprocedure National Institutes of Health Stroke Scale score was 18 (interquartile range, 13–23). The distal occlusion was the primary treatment location in 45 patients, in 23 patients the distal occlusion was treated as a rescue strategy after successful treatment of a proximal large vessel occlusion strokes, and 1 patient had both primary and rescue treatment. The locations of the primary cases were MCA-M3 (n=21), ACA alone (n=8), ACA with a concomitant MCA-M1 or MCA-M2 (n=10), ACA with a concomitant MCA-M3 (n=3), and posterior cerebral artery (n=3). The locations of the rescue cases were MCA-M3 (n=11), ACA (n=7), posterior cerebral artery (n=4), and both MCA-M3 and ACA (n=1). There was a single patient with primary ACA and MCA-M2 occlusions treated, who then had a rescue MCA-M3 thrombectomy addressed after initial reperfusion. The most common treatment modalities used were stent-retrievers (n=37, 54%), intra-arterial tPA (n=36, 52%), and thromboaspiration (n=31, 45%). Near complete or complete reperfusion of the distal territory (modified Treatment In Cerebral Ischemia [mTICI] 2b-3) was achieved in 57 cases (83%). Three parenchymal hematomas (4%) occurred in the territory of the treated distal occlusion with 2 of these patients also receiving intravenous tPA. At 90 days, 21 patients (30%) had a modified Rankin Scale score of 0 to 2 and 14 (20%) had died. Conclusions— Distal intracranial occlusions can be treated safely and successfully with endovascular therapy. These results need to be corroborated by larger prospective controlled studies.

Individuals with mild strokes are generally considered fully functional and do not traditionally receive rehabilitation services. Because patients with mild stroke are assumed to have a good recovery, they may have deficits in other areas, including mental health, that are not addressed. As a result, patients with mild stroke are unable to meet quality of life standards. In addition, healthcare professionals are likely unaware of the potential mental health issues that may arise in mild stroke. To address this gap in knowledge, we review the evidence supporting mental health evaluation and intervention in mild stroke. Specifically, we review comorbid diagnoses including depression, anxiety, fatigue, and sleep disturbances and their potential effects on health and function. Finally, we conclude with general recommendations describing best practice derived from current evidence.

Background: The minimal stroke severity justifying endovascular intervention remains elusive. However, a significant proportion of patients presenting with large vessel occlusion stroke (LVOS) and mild symptoms go untreated and face poor outcomes. We aimed to evaluate the clinical outcomes of patients presenting with LVOS and low symptom scores (National Institutes of Health Stroke Scale [NIHSS] score ≤8) undergoing endovascular therapy (ET). Methods: We performed a retrospective analysis of a prospectively collected ET database between September 2010 and March 2016. Endovascularly treated patients with LVOS and a baseline NIHSS score ≤8 were included. Baseline patient characteristics, procedural details, and outcome parameters were collected. Efficacy outcomes were the rate of good outcome (90-day modified Rankin Scale score 0-2) and of successful reperfusion (modified Treatment in Cerebral Infarction [mTICI] score 2b-3). Safety was assessed by the rate of parenchymal hematoma (parenchymal hematoma type 1 [PH-1] and parenchymal hematoma type 2 [PH-2]) and 90-day mortality. Logistic regression was used to identify predictors of good clinical outcomes. Results: A total of 935 patients were considered; 72 patients with an NIHSS score ≤8 were included. Median [IQR] age was 61.5 years [56.2-73.0]; 39 patients (54%) were men. Mean (SD) baseline NIHSS score, computed tomography perfusion core volume, and ASPECTS were 6.3 (1.5), 7.5 mL (16.1), and 8.5 (1.3), respectively. Twenty-eight patients (39%) received intravenous tissue plasminogen activator. Occlusions locations were as follows: 29 (40%) proximal MCA-M1, 20 (28%) MCA-M2, 6 (8%) ICA terminus, and 9 (13%) vertebrobasilar. Tandem occlusion was documented in 7 patients (10%). Sixty-seven patients (93%) achieved successful reperfusion (mTICI score 2b-3); 52 (72%) had good 90-day outcomes. Mean final infarct volume was 32.2 ± 59.9 mL. Parenchymal hematoma occurred in 4 patients (6%). Ninety-day mortality was 10% (n = 7). Logistic regression showed that only successful reperfusion (OR 27.7, 95% CI 1.1-655.5, p = 0.04) was an independent predictor of good outcomes. Conclusion: Our findings demonstrate that ET is safe and feasible for LVOS patients presenting with mild clinical syndromes. Future controlled studies are warranted.

Background/Aims: The number of tracheostomised patients in the acute care setting are increasing, resulting in an equal need of providers who can safely change tracheostomy tubes without complications. The objective of this retrospective study was to ascertain if trained speech-language pathologists were able to safely and efficiently perform tracheostomy tube changes in the acute care setting with minimal adverse events. Methods: Our retrospective case series spans from June 2010 to March 2015 and was completed at an academic hospital with a level 1 trauma designation. A total of 107 consecutive referrals undergoing a tracheostomy tube change, with a speech-language pathologist, were identified. Success was defined as the placement of the tracheostomy tube into the tracheal lumen with confirmation of placement. Only complications occurring at the time of the tracheostomy tube change were considered and were defined as an airway loss event: oxygen desaturation 5mL; and the inability to perform the attempted tracheostomy tube change for any other reason. Results: All of the tracheostomy tubes changes were performed at the bedside at a mean of 13 days post tracheotomy (range 3–28). A total of 106 (99%) of 107 tracheostomy tubes changes were successfully completed without complications; 83 (79%) of the tracheostomy tubes changes performed were the initial tracheostomy tubes change completed post tracheotomy. The remaining 23 (21%) were a combination of either the second or third change. One, (less than 1%), of the procedures was attempted and discontinued before the removal of the tracheostomy tubes, and referred back to the surgical services and was successfully managed with no untoward effects to the patient. Conclusions: This is the first study to audit the outcome of speech-language pathologists' ability to successfully change a tracheostomy tube. The findings suggest that specially trained speech-language pathologists, acting as part of a multi-disciplinary care team, have the potential to safely change tracheostomy tubes in an acute care setting with the availability of immediate physician and respiratory therapy support. Additional clinical benefits of the speech-language pathologist changing tracheostomy tubes may include earlier facilitation of communication, decannulation and initiation of nutrition/hydration.

BACKGROUND AND PURPOSE Chronic hypoperfusion from athero-stenotic lesions is thought to lead to better collateral recruitment compared to cardioembolic strokes. It was sought to compare collateral flow in stroke patients with atrial fibrillation (AF) versus stroke patients with cervical atherosclerotic steno-occlusive disease (CASOD). METHOD This was a retrospective review of a prospectively collected endovascular database. Patients with (i) anterior circulation large vessel occlusion stroke, (ii) pre-treatment computed tomography angiography (CTA) and (iii) intracranial embolism from AF or CASOD were included. CTA collateral patterns were evaluated and categorized into two groups: absent/poor collaterals (CTA collateral score 0-1) versus moderate/good collaterals (CTA collateral score 2-4). CT perfusion was also utilized for baseline core volume and evaluation of infarct growth. RESULTS A total of 122 patients fitted the inclusion criteria, of whom 88 (72%) had AF and 34 (27%) CASOD. Patients with AF were older (P < 0.01) and less often males or smokers (P = 0.04 and P < 0.01 respectively). Baseline National Institutes of Health Stroke Scale and Alberta Stroke Program Early CT Score were comparable between groups. Collateral scores were lower in the AF group (P = 0.01) with patients having poor collaterals in 28% of cases versus 9% in the CASOD group (P = 0.03). Mortality rates (20% vs. 0%; P = 0.02) were higher in the AF patients whilst rates of any parenchymal hemorrhage (6% vs. 26%; P < 0.01) were higher in the CASOD group. On multivariable analysis, CASOD was an independent predictor of moderate/good collaterals (odds ratio 4.70; 95% confidence interval 1.17-18.79; P = 0.03). CONCLUSIONS Atheroembolic strokes seem to be associated with better collateral flow compared to cardioembolic strokes. This may in part explain the worse outcomes of AF-related stroke.

Introduction: Patent foramen ovale (PFO) is more commonly found in patients with cryptogenic stroke and paradoxical embolism is commonly assumed to be the primary mechanism. Our objective was to determine the frequency of hypercoagulability in cryptogenic stroke patients and PFO. Methods: Consecutive patients with embolic stroke of undetermined source (ESUS) seen at the Emory Clinic from January 1, 2017 to June 30, 2019 who underwent echocardiogram with bubble study and markers of coagulation and hemostatic activation (MOCHA) testing (serum d-dimer, prothrombin fragment 1.2, thrombin-antithrombin complex, fibrin monomer) were included; abnormal MOCHA was defined as ≥ 2 elevated markers. Venous thromboembolism, malignancy, other defined hypercoagulable state, and the composite outcome were assessed at routine follow-up and compared across groups based on PFO status. Results: Of 172 patients (mean age 63 ± 16 years, 60% female), 40 (23%) had a PFO. Compared to the PFO- group, the PFO+ group was younger (p= Conclusion: Hypercoagulability as measured by MOCHA was not associated with the presence of PFO in ESUS patients. Based on our results, ESUS patients should undergo a detailed evaluation for alternative causes of stroke other than paradoxical embolism.

Introduction: We previously reported that markers of coagulation and hemostatic activation (MOCHA) have been associated with malignancy, venous thromboembolism (VTE) and hypercoagulable states in embolic stroke of undetermined source (ESUS) patients. The objective of our study was to identify independent predictors of these endpoints. Methods: Consecutive ESUS patients seen at the Emory Clinic from January 1, 2017 to June 30, 2019 underwent a MOCHA profile (d-dimer, prothrombin fragment 1.2, thrombin-antithrombin complex, fibrin monomer) and were followed prospectively for new diagnoses of malignancy, VTE, other defined hypercoagulable states and the composite outcome. Abnormal MOCHA was defined as ≥ 2 elevated markers. Multivariable analyses were performed to identify predictors of the composite outcome. Results: Of 188 patients (mean age 63 ±16 years, 59% female, 50% Caucasian) included in the study period, 25 (13%) had the composite outcome. The median time between ESUS to MOCHA testing was 45 days (IQR 23-88). Abnormal MOCHA profile was the only independent predictor of the composite outcome (OR 2.34, 1.64-3.32, p Conclusions: This study confirms that a normal MOCHA profile in the post-acute time period can rule out ESUS patients with malignancy, VTE or other underlying hypercoagulable states.

Introduction: Left atrial enlargement (LAE) and markers of coagulation and hemostatic activation (MOCHA) have previously been shown to identify ESUS patients who are more likely to have subsequent diagnosis of atrial fibrillation (AF), malignancy or recurrent strokes. The objective of this study was to evaluate if anticoagulation therapy reduces recurrent stroke in ESUS patients with LAE or abnormal MOCHA. Methods: Consecutive ESUS patients seen in the Emory Clinic from January 1, 2017, to June 30, 2019, underwent outpatient cardiac monitoring and the MOCHA profile (serum d-dimer, prothrombin fragment 1.2, thrombin-antithrombin complex and fibrin monomer) obtained ≥ 2 weeks after the index stroke. All patients were on antiplatelet therapy at the time of testing. Anticoagulation was offered to patients with an abnormal MOCHA (≥ 2 elevated markers) or severe LAE (LA volume index >40 ml/m 2 ). Patients were evaluated for AF, malignancy, recurrent stroke or hemorrhage at routine clinical follow-up. We compared this patient cohort (cohort 2) to a historical cohort (cohort 1) who underwent the same protocol but remained on antiplatelet therapy during follow-up. Results: Baseline characteristics and endpoints are shown in the Table. Overall 46 (23%) patients in Cohort 2 initiated anticoagulation based on abnormal MOCHA or severe LAE. Cohort 2 had significantly lower rates of recurrent stroke than cohort 1 (14% vs. 3%, p=0.008) with no major hemorrhages. Conclusion: Anticoagulation therapy in a subgroup of ESUS patients with abnormal MOCHA or severe LAE may be associated with a reduced rate of recurrent stroke. A prospective, multicenter study is warranted to validate these results.

Introduction: Identification of Large Vessel Occlusion (LVO) in acute ischemic stroke (AIS) patients is critical for proper decision-making. Limited availability of trained experts and delays in LVO recognition can have a detrimental effect on outcomes. We sought to evaluate an artificial intelligence-based algorithm for LVO detection in AIS. Methods: A retrospective analysis of a prospectively-collected database of AIS patients admitted to a large volume stroke center between 2014-2018 was performed. Experienced vascular neurologists graded CTA for presence and site of LVO. Concurrently, studies were analyzed by the Viz-LVO Algorithm® version 1.4 (GA) - a convolutional neural network programmed to detect occlusions from the internal carotid artery terminus (ICA-T) to the sylvian fissure, which would include all MCA M1-segment and most M2-segment lesions. CTA readings were categorized as LVOs (ICA-T, MCA-M1, MCA-M2) versus non-LVOs/more distal occlusions. Comparisons between human and AI-based readings were done by accuracy analysis and calculating Cohen’s kappa. Results: A total of 610 CTAs were analyzed. The AI algorithm rejected 3.4% of the CTAs due to poor quality. Viz-LVO identified LVOs with an overall sensitivity of 81.3%, specificity of 87.8%, and accuracy of 83.2% (AUC 0.845 (95%CI:0.81-0.88, p Conclusion: Our study demonstrates that automated AI reading allows for fast and accurate identification of LVO strokes. Future efforts should be made to improve the detection of the more distal occlusions.

Introduction: Intracerebral hemorrhages (ICHs) accounts for approximately 15% of all strokes but carry high rates of morbidity and mortality. The location and volume of hematoma are strongly associated with outcomes. As novel treatments become established, early detection and proper volume measurement are becoming increasingly important. We aim to evaluate an artificial intelligence-based algorithm (Viz-ICH® v1.4) for ICH detection, volume measurement, and its differentiation from intraventricular hemorrhage (IVH). Methods: We performed single center retrospective analysis of non-contrast CTs (NCCTs), randomly picked from prospective cohort of acute stroke patients, with and without parenchymal ICHs, admitted to our stroke center from 02/14-03/17. Experienced stroke neurologists graded NCCTs with a semi-automated tool (OsiriX MD v.9.0.1) for presence and volume of ICH, and also presence of intraventricular hemorrhage (IVH). AI- and human-based readings were compared. Results: A total of 211 NCCTs were evaluated including 163 ICHs and 48 controls. The ICH location was basal ganglionic in 55.8%, Lobar in 23.3% and posterior fossa in 12% of the cases and 51.5 % of patients had associated IVH with mean volume 41.94 cc. The AI algorithm demonstrated high accuracy for ICH detection and volumetric measurement (Table). The maximal running time of the algorithm was under 15s. Conclusion: The presence and volume of ICHs can be accurately detected by AI Viz-ICH Algorithm, with good differentiation from IVH which will help in early triage of these patients.

Clinical care of acute stroke patients can be handled by multiple specialties yet the concept of “strokophobia”, or the fear of dealing with stroke patients has not been explored in the literature. We explore some of the roots of that fear in residents of the neurology, emergency medicine (EM) and internal medicine (IM) specialties. An anonymous survey was sent to neurology, IM and EM residents at two different academic institutions. The survey inquired about the respondent’s demographics, training, and the first time the had a strong discomfort dealing with stroke. More detailed questions followed regarding some of the common perceived misconceptions and reasons behind the fear of caring for stroke patients. The questionnaire also inquired about some available resources to mitigate that fear. Of the 47 respondents, 47% were male. 57% were in IM, 38% were in neurology, and 4% from EM. 23% were in their PGY1 of training, 30 % were PGY2, 32% PGY3, and 15% PGY4. Most residents (83%) had an inpatient component in their neurology clerkship. 66% report having some fear in dealing with stroke patients. 28% report the fear to originally stem from the clinical years of medical school and 28% during residency. 40% of residents agreed that more neuroanatomy teaching is needed and 36% did not think enough education was given in medical school. 11% did not have a neurology clerkship in their medical school, 4% did not have an opportunity to work with a neurologist in medical school. 25% of residents report having limited exposure to stroke patients. 23% of residents consult neurology out of fear of missing significant pathology, while 23% were not comfortable with their exam skills. 38 % residents blame excessive paperwork for the lack of education while 23% think it was witnessing some attendings uncomfortable with stroke patients. The high acuity of these patients would deter 30% of the residents from caring for them. 11% of residents shy away due to having to establish adequate time windows or asking for help. 72% agree that more hands-on teaching is needed while 38% state that more tutorial videos could be helpful. In this first-ever exploratory analysis of strokophobia, the results show that the phenomenon is prevalent and more education is needed in order to mitigate it amongst residents.

Background. Stroke often involves primary motor cortex (M1) and its corticospinal (CST) projections. As hand function is critically dependent on these structures, its recovery is often incomplete. Objective. To determine whether impaired hand function in patients with chronic ischemic stroke involving M1 or CST benefits from the enhancing effect of Hebbian-type stimulation (pairing M1 afferent stimulation and M1 activity in a specific temporal relationship) on M1 plasticity and hand function. Methods. In a double-blind, randomized, sham-controlled design, 20 patients with chronic ischemic stroke affecting M1 or CST were randomly assigned to 5 days of hand motor training that was combined with either Hebbian-type (trainingHebb) or sham stimulation (trainingsham) of the lesioned M1. Measures of hand function and task-based M1 functional magnetic resonance imaging (fMRI) activity were collected prior to, immediately following, and 4 weeks after the intervention. Results. Both interventions were effective in improving affected hand function at the completion of training, but only participants in the trainingHebb group maintained functional gains. Changes in hand function and fMRI activity were positively correlated in both ipsilesional and contralesional M1. Compared with trainingsham, participants in the trainingHebb group showed a stronger relationship between improved hand function and changes in M1 functional activity. Conclusions. Only when motor training was combined with Hebbian-type stimulation were functional gains maintained over time and correlated with measures of M1 functional plasticity. As hand dexterity is critically dependent on M1 function, these results suggest that functional reorganization in M1 is facilitated by Hebbian-type stimulation. ClinicalTrials.gov Identifier: NCT01569607.

Will I walk again? Speak fluently? Be able to dress myself?During National Stroke Month each May, professionals working with stroke survivors are reminded of a paradox. On the one hand, the postacu...

Potential causes of embolic stroke of undetermined source (ESUS) include occult malignancy, venous thrombosis (VTE) with paradoxical embolism, and hypercoagulable disorders. Given the association of markers of coagulation and hemostatic activation (MOCHA) with these causes, the objective of this study was to validate the utility of the MOCHA profile in identifying the underlying cause of stroke.We prospectively identified ESUS patients from January 1, 2017 to December 1, 2019 who underwent MOCHA profile (plasma d-dimer, prothrombin fragment 1.2, thrombin-antithrombin complex, fibrin monomer) testing. Abnormal MOCHA profile was defined as ≥ 2 abnormal markers. New diagnoses of malignancy, VTE, hypercoagulable disorders and recurrent stroke were identified during routine clinical follow-up.Of 236 ESUS patients, 104 (44%) patients had an abnormal MOCHA profile. In multivariable analyses the number of MOCHA abnormalities was significantly associated with malignancy, VTE, and hypercoagulable disorders (OR 2.59, CI 95% 1.78-3.76, p0.001). Sensitivity, specificity, positive predictive value, and negative predictive value of an abnormal MOCHA profile for the combined outcome of malignancy, VTE, and hypercoagulability was 96%, 62%, 23%, and 99% respectively.The MOCHA profile was able to identify ESUS patients more likely to have malignancy, VTE, and hypercoagulable disorders during follow-up. Our results show that a normal MOCHA profile in ESUS patients can effectively rule out these potential causes of ESUS.

The role of primary motor cortex (M1) in the control of hand movements is still unclear. Functional magnetic resonance imaging (fMRI) studies of unimanual performance reported a relationship between level of precision of a motor task and additional ipsilateral M1 (iM1) activation. In the present study, we determined whether the demand on accuracy of a movement influences the magnitude of the inhibitory effect between primary motor cortices (IHI). We used transcranial magnetic stimulation (TMS) to measure active IHI (aIHI) of the iM1 on the contralateral M1 (cM1) in the premovement period of a left-hand motor task. Ten healthy participants manipulated a joystick to point to targets of two different sizes. For aIHI, the conditioning stimulus (CS) was applied to iM1, and the test stimulus (TS) to cM1, with an interstimulus interval of 10 ms. The amount of the inhibitory effect of the CS on the motor-evoked potential (MEP) of the subsequent TS was expressed as percentage of the mean MEP amplitude evoked by the single TS. Across different time points of aIHI measurements in the premovement period, there was a significant effect for target size on aIHI. Preparing to point to small targets was associated with weaker aIHI compared with pointing to large targets. The present findings suggest that, during the premovement period, aIHI from iM1 on cM1 is modulated by the demand on accuracy of the motor task. This is consistent with task fMRI findings showing bilateral M1 activation during high-precision movements but only unilateral M1 activity during low-precision movements.

Background and Purpose— Intravenous tissue-type plasminogen activator (tPA) treatment in acute stroke has many exclusion criteria. We aimed to assess the safety and efficacy of endovascular therapy (ET) in intravenous (IV) tPA-ineligible patients. Methods— Retrospective analysis of a prospectively collected database of consecutive patients treated with ET within 6 hours of stroke onset between September 2010 and April 2015. Patients treated with IV-tPA followed by ET were compared with those treated with ET alone because of IV-tPA ineligibility. Efficacy and safety end points included the rates of good outcome (90-day modified Rankin scale score ≤2), successful reperfusion (modified Treatment in Cerebral Ischemia 2b-3), parenchymal hematoma (PH-1 and PH-2), and 90-day mortality. Univariate and logistic regression were performed to identify the predictors of outcomes. Results— A total of 422 patients were included. Two hundred and fifty-three (59%) patients received IV-tPA+ET, and 169 (41%), ET alone. Combined IV-tPA+ET patients were slightly younger (64.9±15.2 versus 67.9±14.9 years; P =0.05), more often males (56% versus 44%; P =0.01), and had less hypertension (70% versus 81%; P =0.02) and vertebrobasilar occlusions (3% versus 8%; P =0.02). The remaining baseline characteristics, including National Institutes of Health Stroke Scale score (20 [15–23] versus 19 [15–24]; P =0.85), Alberta Stroke Program Early CT Score (ASPECTS; 8 [7–9] versus 8 [7–9]; P =0.24), and stroke onset to puncture times (235±70 versus 240±81 minutes; P =0.27), were similar across both groups. There were no significant differences in the rates of modified Treatment in Cerebral Ischemia 2b-3 (83% versus 80%; P =0.52), 90-day modified Rankin scale score ≤2 (45% versus 38%; P =0.21), or any PH (3% versus 5%; P =0.21). Unadjusted 90-day mortality was higher with ET alone (21% versus 34%; P Conclusions— IV-tPA-eligible and -ineligible patients seem to have similar outcomes after early ET.

Introduction: Recent randomized trials have shown that patent foramen ovale (PFO) closure combined with antiplatelet therapy in cryptogenic stroke patients ≤ 60 years of age is associated with a reduced risk of stroke compared to antiplatelet therapy alone, presumably by preventing a paradoxical embolism. The objective of this study was to evaluate the MOCHA profile, a sensitive marker of venous thromboembolism (VTE), in ESUS patients with PFO. Methods: Consecutive ESUS patients ≥ 18 years of age seen in the Emory Clinic from January 1, 2017 to June 30, 2018 underwent testing of MOCHA including serum d-dimer (DD), prothrombin fragment 1.2 (PTF1.2), thrombin-antithrombin (TAT) complex and fibrin monomer (FM). All patients were on antiplatelet therapy at the time of MOCHA testing and an abnormal MOCHA profile was defined as ≥ 2 elevated markers. We compared baseline characteristics and clinical outcomes between patients with and without PFO. Results: During the study period, 113 ESUS patients (mean age 64 +/- 15 years, 63% female, 54% non-white, 20% PFO) underwent MOCHA profile testing; 37 (32.7%) were ≤ 60 years of age. In the subgroup ≤ 60 years of age, the 11 (23%) PFO+ patients were younger (mean age 40 vs 46, p=0.009), more likely to be white (55% vs 35%, p=0.0001) and had higher ROPE score (median 8 vs 6, p=0.06) than PFO- patients. There was no significant difference between PFO+ and PFO- patients in the frequency of abnormal MOCHA (18% vs 19%), mean DD, PTF1.2, TAT, FM and frequency of VTE (1 event in each group). PFO+ and PFO- patients had a high frequency of migraine with aura (64%, 38%, p=0.15) and headache days in the month prior to stroke (mean 11 vs 5, p=0.72). In multivariable analysis of the overall cohort, age (OR 1.14 1.06-1.22 p Conclusion: In ESUS patients ≤ 60 years of age, there was no difference in the MOCHA profile between PFO+ and PFO- patients. The high frequency of migraine with aura and headache days in the month prior to stroke regardless of PFO status needs further study to evaluate its role in young ESUS patients.

Introduction: Markers of coagulation and hemostatic activation (MOCHA) have previously been shown to identify ESUS patients who are more likely to have subsequent diagnosis of atrial fibrillation (AF) or malignancy. The objective of this study was to validate these results in a larger ESUS cohort. Methods: Consecutive ESUS patients seen in the Emory Clinic from January 1, 2017 to June 30, 2018 underwent outpatient cardiac monitoring and the MOCHA profile including serum d-dimer, prothrombin fragment 1.2, thrombin-antithrombin complex and fibrin monomer obtained ≥ 2 weeks after the index stroke. All patients were on antiplatelet therapy at the time of MOCHA testing and an abnormal MOCHA profile was defined as ≥ 2 elevated markers. Prespecified endpoints monitored during routine clinical follow-up included diagnosis of AF, malignancy, venous thromboembolism (VTE) or other defined hypercoagulable states. Results: During the study period, 113 ESUS patients (mean age 64 +/- 15 years, 63% female, 54% non-white) underwent prolonged cardiac monitoring (70% MCOT, 42% ILR) and MOCHA profile testing (median days from stroke 33, IQR 15-57). During a mean follow-up of 7 ± 4 months, AF, malignancy, VTE or other defined hypercoagulable state was identified in 30 (27%) patients; the 41 (36%) ESUS patients with an abnormal MOCHA profile were significantly more likely to have an endpoint than patients with a normal profile (59% vs 8%, p Conclusion: In this validation study, we found that the MOCHA profile identified ESUS patients more likely to have AF, malignancy, VTE or other defined hypercoagulable states during follow-up and may identify a subgroup of ESUS patients who could benefit from early anticoagulation; a normal MOCHA profile identifies ESUS patients who have a low risk of developing these endpoints on antiplatelet therapy.

Introduction: The standard reperfusion target for thrombectomy trials has been modified TICI (mTICI) 2b-3 (≥50% ischemic territory). Recently, full reperfusion (mTICI 2c-3) has been recommended as the ideal target. The potential added benefits of additional procedural maneuvers must be balanced against their risks, particularly when dealing with residual distal occlusions often found in mTICI 2b. It remains unknown whether more precise categorization of the mTICI2b strata leads to more reasonable treatment targets. Methods: Retrospective analysis of prospectively collected thrombectomy data spanning Jun 2011-Feb 2018. Inclusion criteria: MCA and intracranial internal carotid artery occlusions. Definitions of reperfusion: mTICI0-1: no or limiteddistal filling; mTICI2a: Results: Of 557 patients, 2.2% had mTICI0-1, 3.6% had mTICI2a, 5.9% had mTICI2b-, 30.2% mTICI2b+, and 58.2% mTICI3. The usage of intravenous tPA was lower in the mTICI2b- vs. mTICI3 (18% vs. 41%;pFigure ). Mortality rates were comparable across the mTICI2b-, mTICI 2b+, and mTICI 3 groups but higher with mTICI2a (40%;p=0.01) and mTICI0-1 (50%;p Conclusion: There is broad variation in outcomes across the different degrees of reperfusion within the mTICI 2b grade. A reperfusion target of 75%-99% (mTICI2b+) may lead comparable rates of independence versus full reperfusion.

Introduction: Markers of coagulation and hemostatic activation (MOCHA) have previously been shown to identify ESUS patients who are more likely to have subsequent diagnosis of atrial fibrillation (AF), malignancy, venous thromboembolism (VTE) or other defined hypercoagulable disorders. The objective of this study was to evaluate whether anticoagulation therapy reduces recurrent stroke in ESUS patients with an abnormal MOCHA profile. Methods: Consecutive ESUS patients seen in the Emory Clinic from January 1, 2017 to June 30, 2018 underwent outpatient cardiac monitoring and the MOCHA profile including serum d-dimer, prothrombin fragment 1.2, thrombin-antithrombin complex and fibrin monomer obtained ≥ 2 weeks after the index stroke. All patients were on antiplatelet therapy at the time of MOCHA testing and an abnormal MOCHA profile was defined as ≥ 2 elevated markers. Anticoagulation was offered to patients with an abnormal MOCHA and patients were evaluated for recurrent stroke or hemorrhage at routine clinical follow-up. We compared this patient cohort (cohort 2) to a historical cohort (cohort 1) who underwent the same protocol but remained on antiplatelet therapy during follow-up. Results: Baseline characteristics were similar between cohorts except that cohort 2 was less likely to have diabetes (43% vs 23%, p=0.004), less likely to have an abnormal MOCHA profile (55% vs 36%, p=0.008) and had a shorter duration of follow-up (mean months 13 vs 7, p=0.0001). Cohorts had similar rates of the composite endpoint of AF, malignancy, VTE or other defined hypercoagulable disorder (33% vs 26%, p=0.43). MOCHA profile was obtained a median of 33 (IQR 15-57) days after index stroke in cohort 2; 41 (36%) patients were offered the option of anticoagulation therapy due to an abnormal MOCHA profile of which 32 (78%) chose anticoagulation. Cohort 2 had significantly lower rates of recurrent stroke than cohort 1 (14% vs. 0.9%, IRR 0.14, p=0.01) with no major hemorrhages seen in either group. Conclusion: This study suggests that anticoagulation therapy in a subgroup of ESUS patients with abnormal MOCHA profile may be associated with a reduced rate of recurrent stroke. A prospective, randomized study is needed to confirm these findings.

Cerebral venous thrombosis is a relatively uncommon disease as compared to the cerebral arterial infarct, but it is a disabling disease condition with serious sequels. It negatively affects the quality of life of many survivors. Its disease course and recovery trajectory have not been well investigated with limited dedicated studies, especially studies focusing on functional recovery. This narrative chapter will review the published literatures and summarize the general recovery pattern, major determinants of recovery with a special emphasis on outcomes prediction, mechanisms of the recovery, and special consideration in certain clinical scenarios. In the end, future research direction is highlighted and proposed.

Stroke often involves primary motor cortex (M1) and its corticospinal projections (CST). As hand function is critically dependent on these structures, its recovery is often incomplete. The neuronal substrate supporting affected hand function is not well understood but likely involves reorganized M1 and CST of the lesioned hemisphere (M1IL and CSTIL). We hypothesized that affected hand function in chronic stroke is related to structural and functional reorganization of M1IL and CSTIL. We tested 18 patients with chronic ischemic stroke involving M1 or CST. Their hand function was compared with 18 age-matched healthy subjects. M1IL thickness and CSTIL fractional anisotropy (FA) were determined with MRI and compared with measures of the other hemisphere. Transcranial magnetic stimulation (TMS) was applied to M1IL to determine its input-output function [stimulus response curve (SRC)]. The plateau of the SRC (MEPmax), inflection point, and slope parameters of the curve were extracted. Results were compared with measures in 12 age-matched healthy controls. MEPmax of M1IL was significantly smaller ( P = 0.02) in the patients, indicating reduced CSTIL motor output, and was correlated with impaired hand function ( P = 0.02). M1IL thickness ( P < 0.01) and CSTIL-FA ( P < 0.01) were reduced but did not correlate with hand function. The results indicate that employed M1IL or CSTIL structural measures do not explain the extent of impairment in hand function once M1 and CST are sufficiently functional for TMS to evoke a motor potential. Instead, impairment of hand function is best explained by the abnormally low output from M1IL. NEW & NOTEWORTHY Hand function often remains impaired after stroke. While the critical role of the primary motor cortex (M1) and its corticospinal output (CST) for hand function has been described in the nonhuman primate stroke model, their structure and function have not been systematically evaluated for patients after stroke. We report that in chronic stroke patients with injury to M1 and/or CST an abnormally reduced M1 output is related to impaired hand function.

Background and Purpose: Craniocervical fibromuscular dysplasia (FMD) is associated with dissections and with S-shaped curves in the internal carotid artery (ICA). We evaluated the occurrence of S-curves in patients presenting with acute strokes due to ICA steno-occlusive dissections. Methods: This was a retrospective review of the interventional databases of two academic tertiary-care institutions. The presence of ICA S-shaped curves, C-shaped curves, 360-degree loops, as well as classic FMD and atherosclerotic changes at the ICA bulb and curve/loop was determined. Cases of carotid dissections were compared with a control group (consecutive non-tandem anterior circulation strokes). Results: Twenty-four patients with carotid dissections were compared to 92 controls. Baseline characteristics and procedural variables were similar, with the exception of younger age, less frequent history of hypertension, diabetes, atrial fibrillation and stent retriever use in patients with dissections. The rates of mTICI2b-3 reperfusion, parenchymal hematoma, good outcome and mortality were similar amongst groups. The frequency of S-curves (any side without superimposed atherosclerosis) was 29% in the dissection group versus 7% in controls (p < 0.01). S-curves were typically mirror images within the dissection group (85% had bilateral occurrence). The frequency of C-shaped and 360-degree curves was similar between groups. FMD changes within the craniocervical arteries were statistically more common in dissection patients. Ten patients (41%) of the dissection group had S-curves or classic FMD changes. Multivariate analysis indicated that S-curves were independently associated with the presence of dissections. Conclusion: S-shaped ICA curves are predictably bilateral, highly associated with carotid dissections in patients with moderate to severe strokes, and may suggest an underlying presence of FMD.

Background: Patients who are admitted during off-hours (nights and weekends) are thought to have worse outcomes. This might be explained by delayed times to treatment. We sought to determine the effect of off-hour presentation on processes of care and outcomes at a comprehensive stroke center. Methods: We reviewed our prospectively collected endovascular database at a tertiary care academic institution between Sep 2010-Dec 2016. All patients that underwent endovascular therapy for large vessel occlusion acute ischemic stroke were included and categorized into two groups: those arriving during regular hours (weekday 7AM-7PM) or off-hours. The 2 groups were then matched for age, baseline NIHSS and glucose levels using a weighted Euclidian distance method. Baseline, procedural, and radiological characteristics, as well as outcome parameters were compared. Results: 926 (463 pairs) patients were included. Patients presenting off-hours had higher rates of hypertension (78.2% vs 66.7%, p Conclusions: Our study shows that patients presenting off-hours have similar picture to puncture times and clinical outcomes as those presenting during regular hours.

Background: Hyperglycemia on admission is known to be associated with poor outcome after intravenous or intra-arterial thrombolysis treatment in patient with acute ischemic stroke. However, its effect on mechanical thrombectomy outcomes remains elusive. We investigated whether clinical and procedural outcomes differ between normoglycemic and hyperglycemic patients with large vessel occlusion stroke after endovascular therapy. Methods: We reviewed our prospectively collected endovascular database at a tertiary care academic institution between 9/2010-12/2016. Hyperglycemia was defined as admission serum glucose >140mg/dl. All patients that underwent ET for anterior circulation large vessel occlusion acute ischemic stroke were included and categorized into two groups according to their glycemic status. Baseline and procedural characteristics, as well as outcome parameters were compared. Results: A total of 931 patients qualified for the study of which 289 (31%) had hyperglycemia on admission. Those with hyperglycemia were older (p=0.001), had more comorbidities and more severe strokes as assessed by the NIHSS (19[15-23] vs 17[13-21], p=0.01). In univariate analysis, Hyperglycemic patients had lower rates of successful reperfusion (mTICI2b-3, 85.4% vs 90.6%,, p=0.02) and 90-day good outcomes (mRS 0-2, 32.7% vs 52.3%, p Conclusions: Our study confirms that hyperglycemia is associated with poorer procedural and clinical outcomes in patients undergoing mechanical thrombectomy for large vessel occlusion strokes.

Background: Obesity has been associated with increased morbidity and mortality in the general population. However, several reports have described lower mortality rates in overweight or obese patients as compared to normal weight ones. Several studies have investigated the phenomenon, commonly known as the obesity paradox, with mixed results thus far. We sought to determine whether clinical outcomes differ between patients with acute ischemic stroke after endovascular therapy according to their body mass index (BMI). Methods: We reviewed our prospectively collected endovascular database at a tertiary care academic institution. All patients that underwent endovascular therapy for acute large vessel occlusion acute ischemic stroke were categorized according to their BMI into four groups (1) underweight (BMI30). Baseline characteristics, procedural radiological as well as outcome parameters were compared. Results: A total of 926 patients qualified for the study of which 20 (2.2%) were underweight, 253 (27.3%) had a normal weight, 315 (34%) were overweight and 338 (36.5%) obese. When compared with normal weight (reference) overweight patients had higher rates of dyslipidemia as well as diabetes and higher glucose and HbA1c levels while obese patients were younger, less often smokers and had higher rates of hypertension as well as diabetes and higher glucose and HbA1c levels. Other baselines characteristics including NIHSS and ASPECT scores as procedural characteristics were comparable between groups. In terms of outcomes, rates of successful reperfusion (mTICI 2b-3), parenchymal hematomas, 90-Day good clinical outcomes (modified Rankin scale, mRS 0-2) and 90-day mortality were comparable between BMI groups. On multivariate analysis, BMI was not associated with good outcomes nor mortality whether as a continuous variables or a categorical variable comparing groups with normal weight patients (reference) two by two. Conclusions: In stroke patients treated with mechanical thrombectomy, BMI does not seem to be associated with outcomes. However, patients who are overweight or obese have more co-morbities and should strive for a normal weight.

Background: The impact of oversized stent-retrievers in reperfusion rates during thrombectomy is unclear. Devices matching the vessel diameter may lead to proportionally larger cells and facilitate device-clot integration. We aim to evaluate if the device diameter may impact reperfusion rates in stroke thrombectomy. Methods: This is a retrospective analysis of a prospectively collected database from a single comprehensive stroke center. We included patients with intracranial carotid occlusions in which stent-retrievers (Trevo or Solitaire devices) were used as the first strategy, from September 2010-March 2017, and compared the 4mm vs 6mm diameter groups. 3mm devices and other retriever-like devices were excluded. Primary outcome was first pass reperfusion (modified TICI2b-3 with the first device pass). Results: Of the 1204 thrombectomies performed within the study period, 150 met inclusion criteria (Trevo: 64/Solitaire: 86/6mm device:67 /4mm: 83). Age, gender, comorbidities and the use of IV tPA were comparable between groups. NIHSS was similar between the 4mm vs 6mm devices (19[14-22] vs 18.5[14-22];p=0.64), as well as time from last normal to puncture (403[260-626] minutes vs 344 [209-816];p=0.54), and ASPECTS (7[6-9] vs 8[7-9];p=0.25), respectively. Patients with 4mm devices had less tandem disease (11% vs 28%,p=0.01). The use of local aspiration was similar between groups (7vs9%p=0.76) for the 4mm and 6mm devices. First-pass mTICI2b-3/mTICI3 reperfusion was achieved in similar proportion between the 4mm vs 6mm groups: 52%vs.56%;p=0.62 / 32%vs22%;p=0.20, respectively. Parenchymal hematomas (16% vs 9%;p=0.22) and subarachnoid hemorrhage (5% vs 7%;p=0.74) were similar between the 4mm and 6mm arms. Independent outcome at 3months was more common in the 4mm vs 6mm groups (28%vs50%;p=0.03). Multivariable analysis indicated mRS0-2 at 90-days independently associated with first-pass reperfusion and demonstrated no impact of device diameter on first-pass reperfusion. Conclusions: The use of 6mm stent retrievers for intracranial carotid occlusions had demonstrated benefit over 4mm devices for chances of first pass reperfusion.

Introduction: The objective of this study was to evaluate left atrial (LA) echocardiographic parameters and a novel panel of serum biomarkers to identify ESUS patients who may benefit from early anticoagulation. Methods: We prospectively identified ESUS patients seen in the Emory Clinic from January 1, 2015 to June 30, 2017 who underwent prolonged cardiac monitoring with mobile cardiac outpatient telemetry (MCOT) and/or implantable loop recorder (ILR). In a subset of consecutive patients, 4 measures of coagulation and hemostatic activation (MOCHA) including d-dimer, prothrombin fragment 1.2, thrombin-antithrombin complex and fibrin monomer were obtained ≥ 2 weeks after the index stroke and repeated if abnormal. We evaluated the ability of LA structural parameters to identify patients with atrial fibrillation (AF) on monitoring and the ability of abnormal MOCHA levels to identify patients who had the composite outcome of newly diagnosed AF, malignancy, or recurrent stroke. Results: During the study period, 92 ESUS patients (mean age 64 +/- 15 years, 54% female, 62% non-white, mean follow-up 1.4 +/- 0.8 years) underwent prolonged cardiac monitoring (65% MCOT, 62% ILR, 38% MCOT+ILR); 16 (17%) were found to have AF. Severe LA enlargement (vs normal) was associated with subsequent detection of AF (p=0.09) however LA diameter and LA volume index were not. Baseline characteristics of ESUS patients who underwent MOCHA testing (n=44) were similar to patients who did not except that those tested were younger (60 vs 67 years, p=0.04); over mean follow-up of 1.2 +/- 0.8 years, 18 (41%) patients had newly diagnosed AF, malignancy or recurrent stroke. ESUS patients with persistently abnormal (vs normal) MOCHA levels were significantly more likely to have newly diagnosed AF, malignancy or recurrent stroke (OR 11.3, 95% CI 2.5-50.1, p=0.001); elevated levels of ≥ 3 MOCHA markers had a 67% sensitivity and 81% specificity for identifying patients with the composite outcome. Conclusion: Abnormal MOCHA levels identified ESUS patients who were more likely to have newly diagnosed AF, malignancy or recurrent stroke over follow-up and may be more effective than LA structural abnormalities in identifying patients who could benefit from early anticoagulation.

Background and Purpose: Smoking is a well-established risk factor for stroke. However, several studies have shown that smokers with stroke have better outcomes after thrombolysis, a phenomenon commonly known as the smoking-thrombolysis paradox. We investigated whether clinical and procedural outcomes differ between smokers and non-smokers with large vessel occlusion stroke after endovascular therapy. Methods: We reviewed our prospectively collected endovascular database at a tertiary care academic institution between Sep 2010-Dec 2016. All patients that underwent endovascular therapy for anterior circulation large vessel occlusion acute ischemic stroke were included and categorized into two groups: (1) current smokers and (2) non-smokers. The 2 groups were then matched for age, baseline NIHSS and glucose levels using a weighted Euclidian distance method. Baseline, procedural, and radiological characteristics, as well as outcome parameters were compared. Results: A total of 326 (163 matched pairs) qualified for the study. Smokers had higher rates of dyslipidemia (48.5% vs 28.8%, p Conclusion: Our data shows that smoking is not associated with outcomes in patients with large vessel occlusion stroke treated with mechanical thrombectomy.

Background: Little is known on the outcomes of nonagenarians treated with endovascular therapy for acute large vessel occlusion stroke. It is unclear whether they have worse clinical outcomes than octogenarians. Methods: We reviewed our prospectively collected endovascular database at a tertiary care academic institution between Sep 2010-Dec 2016. All patients older than 80 years that underwent endovascular therapy for large vessel occlusion acute ischemic stroke were included and categorized into two groups: 80-89 years (octogenarians), and 90-99 years (nonagenarians). Baseline, procedural, and radiological characteristics, as well as outcome parameters were compared. Results: Thirty-one nonagenarians and 181 octogenarians were treated over the 6-year study period. When compared with octogenarians, nonagenarians had lower glucose levels (121±26 vs 138±46, p Conclusions: Our study shows that there is no significant difference in procedural and clinical outcomes between nonagenarians and octogenarians treated with endovascular therapy. Baseline stroke severity and successful reperfusion are the main drivers of favorable functional outcome in patients ≥80years old.

Primary motor cortex (M1) plasticity is involved in motor learning and stroke motor recovery, and enhanced by increasing monoaminergic transmission. Age impacts these processes but there is a paucity of systematic studies on the effects of monoaminergic drugs in older adults. Here, in ten older adults (age 61 + 4 years, 4 males), we determine the effects of a single oral dose of carbidopa/levodopa (DOPA), D-amphetamine (AMPH), methylphenidate (MEPH) and placebo (PLAC) on M1 excitability and motor training-induced M1 plasticity. M1 plasticity is defined as training related long lasting changes in M1 excitability and kinematics of the trained movement. At peak plasma level of the drugs, subjects trained wrist extension movements for 30 min. Outcome measures were motor evoked potentials (MEPs) elicited by transcranial magnetic stimulation at increasing intensity (stimulus response curve, SRC) and peak acceleration of the trained wrist extension movements. Measures were obtained before and after completion of training. The curve parameters plateau (MEPmax), inflection point, and slope were extracted from SRC. At baseline drugs had a differential effect on curve parameters, while kinematics remained unchanged. Training alone (PLAC) increased MEPmax but did not improve kinematics. Drugs affected training-related changes of the curve parameters differently, but did not enhance them or kinematics when compared to PLAC. The results demonstrate that in the older adults, MEPH, DOPA, or AMPH have differential effects on baseline M1 excitability and training-related M1 plasticity but fail to enhance them above the naïve level.

Background and Purpose: The objective of our study was to evaluate magnetic resonance imaging (MRI) and echocardiographic characteristics that would identify patients with cryptogenic ischemic stroke (IS) and transient ischemic attack (TIA) who subsequently developed paroxysmal atrial fibrillation (PAF) on mobile cardiac outpatient telemetry (MCOT). Methods: All patients with cryptogenic IS or TIA seen at the Emory University Hospital and Emory University Hospital Midtown from January 1, 2009, to June 30, 2013, who underwent MCOT were included in this analysis. Location (cortical, high subcortical, or neither) of current and prior strokes on MRI and left atrial (LA) functional and anatomical echocardiographic parameters were evaluated to determine their association with subsequent detection of PAF. Results: Of 132 patients, 17 (13%) had evidence of newly diagnosed PAF on MCOT (mean duration of monitoring = 25 days). The presence (vs absence) of ≥1 cortical infarct on baseline MRI was a significant predictor of identifying PAF (odds ratio: 5.2, 95% confidence interval: 1.3-19; P = .01). On baseline echocardiography, patients who had PAF (vs non-PAF) had significantly higher mean LA diameters (4.2 vs 3.7 cm, P = .03) and lower tissue Doppler velocity (a’; 5.5 vs 13.5 cm/s, P = .03). In receiver operating characteristic analysis, the ratio of LA volume index to the septal Doppler velocity (LAVI/a’) of >4.6 was associated with a higher likelihood of PAF. Combining MRI with echocardiographic variables did not improve the predictive ability beyond echocardiography alone. Conclusion: Although the presence of cortical-based infarcts on MRI in patients with cryptogenic IS or TIA increases the likelihood of detecting PAF on MCOT, LA functional and anatomic parameters alone best predicted which patients subsequently had PAF.

Stroke is the fourth leading cause of death in the United States, but remains a leading cause of disability. As more stroke victims survive with advanced acute care, effective strategies and interventions are required to optimize poststroke outcomes. In recent years, knowledge with respect to stroke recovery has expanded greatly through completion of preclinical and clinical trials. Emerging technology may provide further treatment options beyond the standard therapy and practices. In this article, the authors review recent advances in stroke recovery and rehabilitation, including the major determinants of poststroke recovery, challenges in translational stroke recovery research, and several emerging rehabilitation modalities such as noninvasive brain stimulation, brain-computer interface, biotherapeutics, and pharmacologic agents. Potential future directions in research are also addressed.

Background— Comprehensive stroke centers allow for regionalization of subspecialty stroke care. Efficacy of endovascular treatments, however, may be limited by delays in patient transfer. Our goal was to identify where these delays occurred and to assess the impact of such delays on patient outcome. Methods and Results— This was a retrospective study evaluating patients treated with endovascular therapy from November 2010 to July 2012 at our institution. We compared patients transferred from outside hospitals with locally treated patients with respect to demographics, imaging, and treatment times. Good outcomes, as defined by 90-day modified Rankin Scale scores of 0 to 2, were analyzed by transfer status as well as time from initial computed tomography to groin puncture (“picture-to-puncture” time). A total of 193 patients were analyzed, with a mean age of 65.8±14.5 years and median National Institutes of Health Stroke Scale score of 19 (interquartile range, 15–23). More than two thirds of the patients (132 [68%]) were treated from referring facilities. Outside transfers were noted to have longer picture-to-puncture times (205 minutes [interquartile range, 162–274] versus 89 minutes [interquartile range, 70–119]; P 7: 50% versus 76%; P P =0.003). In a logistic regression model, picture-to-puncture times were independently associated with good outcomes (odds ratio, 0.994; 95% confidence interval, 0.990–0.999; P =0.009). Conclusions— Delays in picture-to-puncture times for interhospital transfers reduce the probability of good outcomes among treated patients. Strategies to reduce such delays herald an opportunity for hospitals to improve patient outcomes.

Introduction: Periodic limb movements (PLMs) and obstructive sleep apnea (OSA) have been associated with an increased risk of cardiovascular disease. There are limited data on the frequency of PLMs and OSA among a diverse cohort of stroke patients and their association with resistant hypertension and atrial fibrillation (AF). Hypothesis: Stroke and TIA patients with PLMs or moderate-severe OSA are more likely to have resistant hypertension and AF than patients without these findings on diagnostic polysomnography (PSG). Methods: Consecutive stroke and TIA patients referred by a vascular neurologist for PSG from October 1, 2012 to September 30, 2015 were included in this analysis. Baseline clinical characteristics and PSG results were collected retrospectively. The frequency of PLMs (mild ≥5/hour, severe ≥15/hour), arousals due to PLMs (≥5/hour), and moderate-severe OSA (Apnea-Hypopnea Index≥15) was evaluated by PSG to determine their association with AF and resistant hypertension, defined as patients whose blood pressure was not at goal with 3 antihypertensive agents of different classes or controlled with 4 or more medications. Results: Of 103 patients (mean age 60±15 years, 50% female, 61% non-white, 76% ischemic stroke, 23% resistant hypertension) who underwent PSG (median time from cerebrovascular event to PSG 5 months), 48% had mild PLMs, 28% had severe PLMs, 14% had frequent PLM arousals and 22% had moderate-severe OSA. In multivariable analyses, non-white race was associated with lower likelihood of mild (OR 0.32, 95% CI 0.13 to 0.80) and severe PLMs (OR 0.29, 95% 0.10 to 0.79) and female sex was associated with lower likelihood of frequent PLM arousals (OR 0.38, 95% CI 0.14 to 1.00). Factors associated with moderate-severe OSA included older age (OR 1.06, 95% CI 1.016 to 1.106) and the presence of AF (OR 4.26, 95% CI 1.17 to 15.44). There was no significant association between PLMs, PLM arousals or moderate-severe OSA with resistant hypertension. Conclusions: A significant number of stroke and TIA patients have PLMs and moderate-severe OSA. Stroke and TIA patients with AF are more likely to have moderate-severe OSA and should be referred for PSG. The presence of resistant hypertension was not associated with PLMs or moderate-severe OSA in our study.