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Background Stroke knowledge is critical to treatment adherence and poststroke outcomes. Here, we aimed to quantify the impact of a personalized video‐based educational platform to test the hypothesis that it improves patient satisfaction and stroke knowledge. Methods and Results In a single‐center pilot randomized trial, all patients with stroke and caregivers received standard stroke education during the hospitalization, but half were randomized to receive access to MyStroke, a personalized educational platform that provided brief videos about their stroke, risk factors, medications, and poststroke lifestyle. Satisfaction, stroke knowledge, and quality of life were assessed 7, 30, and 90 days after discharge. A total of 120 subjects (96 patients and 24 caregivers) were randomized to standard education (n=59) or MyStroke. At 90 days post‐stroke, those who received MyStroke were more likely to be satisfied with the stroke education the received (90% versus 73%, P=0.05) and more likely to correctly identify their stroke cause (67% versus 32%, P=0.003). However, MyStroke was not associated with a difference in self‐reported quality of life (EuroQol Visual Analogue Scale: 80 versus 75, P=0.06) or general stroke knowledge (total Stroke Patient Education Retention: 5 versus 5, P=0.47). With respect to secondary end points, MyStroke increased risk factor awareness 7 and 30 days poststroke, but this difference was not significant at 90 days. Conclusions The MyStroke personalized video‐based education platform improved patient and caregiver satisfaction while improving some aspects of personalized stroke knowledge without improving general stroke knowledge. A multicenter trial is needed to confirm these results, clarify generalizability, and target clinically relevant metrics such as stroke recurrence or adherence. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT05118503.

Background The modified Rankin Scale (mRS) is commonly used to measure disability after stroke, traditionally assessed through telephone or in‐person evaluation. Here, we investigated the validity of mRS assessment through an automated text messaging system based on the simplified mRS questionnaire as an alternative method to traditional methods of assessment. Methods and Results A total of 250 patients admitted to 3 hospitals within the University of Pennsylvania Health System with ischemic or hemorrhagic stroke were enrolled. Participants received automated text messages sent 48 hours before their outpatient appointment at about 90 days after stroke. The mRS scores were assigned on the basis of participant responses to 2 to 4 text questions eliciting yes/no responses. The mRS was then evaluated in person or by telephone interview for comparison. Responses were compared with κ. A total of 142 patients (57%) completed the study. The spontaneous response rate to text messages was 46.5% and up to 72% with an additional direct in‐person or phone call reminder. Agreement was substantial (quadratic‐weighted κ=0.87 [95% CI, 0.83–0.89]) between responses derived from the automated text messaging and traditional interviews. Agreement for distinguishing functional independence (mRS 0–1) from dependence (mRS 2–5) was substantial (unweighted κ=0.79 [95% CI, 0.69–0.90]). Conclusions An automated text messaging system is a feasible method for remotely obtaining the mRS after stroke and a potential alternative to traditional in‐person or telephone assessment. Further studies are needed to evaluate the generalizability of text message–based approaches to stroke outcome measurement.

Background Sex differences in presentation, treatment, and prognosis of cardiovascular disorders are well recognized. Although an association between acute myocardial injury and mortality after ischemic stroke has been demonstrated, it is unclear whether prevalence and outcome of poststroke acute myocardial injury differ between women and men. Methods and Results We prospectively screened consecutive patients with acute ischemic stroke and serial high‐sensitivity cardiac troponin T measurements admitted to our center. Acute myocardial injury was defined as at least 1 high‐sensitivity cardiac troponin T value above the upper reference limit (14 ng/L) with a rise/fall of >20%. Rates of acute myocardial injury were also calculated using sex‐specific high‐sensitivity cardiac troponin T cutoffs (women upper reference limit, 9 ng/L; men upper reference limit, 16 ng/L). Logistic regression analyses were performed to evaluate the association between acute myocardial injury and outcomes. Of 1067 patients included, 494 were women (46%). Women were older, had a higher rate of known atrial fibrillation, were more likely to be functionally dependent before admission, had higher stroke severity, and more often had cardioembolic strokes (all P values

Background Elevated cardiac troponin (cTn) is detected in 10% to 30% of patients with acute ischemic stroke (AIS) and correlates with poor functional outcomes. Serial cTn measurements differentiate a dynamic cTn pattern (rise/fall >20%), specific for acute myocardial injury, from elevated but stable cTn levels (nondynamic), typically attributed to chronic cardiac/noncardiac conditions. We investigated if the direction of the cTn change (rising versus falling) affects mortality and outcome. Methods and Results We retrospectively screened consecutive patients with AIS admitted to 5 stroke centers for elevated cTn at admission and at least 1 additional cTn measurement within 48 hours. The pattern of cTn was defined as rising if >20% increase from baseline, falling if >20% decrease, or nondynamic if ≤20% change in either direction. Logistic regression analyses were performed to assess the association of cTn patterns and 7‐day mortality and unfavorable discharge disposition. Of 3789 patients with AIS screened, 300 were included. Seventy‐two had a rising pattern, 66 falling, and 162 nondynamic. In patients with AIS with rising cTn, acute ischemic myocardial infarction was present in 54%, compared with 33% in those with falling cTn (P

Background Complex aortic plaque (CAP) is a potential embolic source in patients with cryptogenic stroke (CS). We review CAP imaging criteria for transesophageal echocardiogram (TEE), computed tomography angiography (CTA), and magnetic resonance imaging and calculate CAP prevalence in patients with acute CS. Methods and Results PubMed and EMBASE databases were searched up to December 2022 in accordance with the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guideline. Two independent reviewers extracted data on study design, imaging techniques, CAP criteria, and prevalence. The Cochrane Collaboration tool and Guideline for Reporting Reliability and Agreement Studies were used to assess risk of bias and reporting completeness, respectively. From 2293 studies, 45 were reviewed for CAP imaging biomarker criteria in patients with acute CS (N=37 TEE; N=9 CTA; N=6 magnetic resonance imaging). Most studies (74%) used ≥4 mm plaque thickness as the imaging criterion for CAP although ≥1 mm (N=1, CTA), ≥5 mm (N=5, TEE), and ≥6 mm (N=2, CTA) were also reported. Additional features included mobility, ulceration, thrombus, protrusions, and assessment of plaque composition. From 23 prospective studies, CAP was detected in 960 of 2778 patients with CS (0.32 [95% CI, 0.24–0.41], I2=94%). By modality, prevalence estimates were 0.29 (95% CI, 0.20–0.40; I2=95%) for TEE; 0.23 (95% CI, 0.15–0.34; I2=87%) for CTA and 0.22 (95% CI, 0.06–0.54; I2=92%) for magnetic resonance imaging. Conclusions TEE was commonly used to assess CAP in patients with CS. The most common CAP imaging biomarker was ≥4 mm plaque thickness. CAP was observed in one‐third of patients with acute CS. However, high study heterogeneity suggests a need for reproducible imaging methods.

Introduction Background: Thrombectomy improves outcomes in patients with basilar artery (BA) occlusion [1,2]. We hypothesized that the anatomic configuration of the BA bifurcation, classified as T‐ or Y‐shaped, may impact the outcome. Specifically, we expected that a T‐shaped BA would involve more deep penetrating arteries of the midbrain and thalamus, leading to greater disability or death [3,4]. Methods In this 2‐center retrospective cohort study over seven years, we included patients with stroke due to distal BA occlusion and performed blinded classification of their BA anatomy as either T‐ or Y‐shaped [Figure 1]. The primary outcomes were favorable functional status at 90 days (modified Rankin Scale 0 – 2) and successful reperfusion (TICI scores 2B or 3). Results 70 patients (mean age 66 years, 36% women) were included. 38 had T‐ and 32 had Y‐shaped bifurcations. Baseline characteristics were similar for both groups, including demographics, treatment time, baseline NIHSS, THRIVE score, posterior circulation collateral score, and presence of tandem occlusion. Comparing the T‐ to the Y‐ shape, there was no difference in the likelihood of successful reperfusion (1.09 [0.52–2.27], p=1.00) nor 90‐day favorable mRS (0‐2) score (RR: 0.68 [0.37–1.27]; p=0.18). Similarly, mortality at 30 and 90 days were not significantly affected by the type of bifurcation. Conclusion The configuration of the basilar artery does not significantly impact reperfusion success or stroke outcome.

Introduction Endovascular thrombectomy (EVT) dramatically improves clinical outcomes, but the reduction in final infarct volume only accounts for 10‐15% of the treatment benefit. There is a clear need for imaging biomarkers that are strongly associated with long‐term functional outcome after EVT, both in clinical practice and clinical trial design (surrogate outcome measure). Here we aimed to quantify the relationship between functional outcome and a range of ADC thresholds on post‐EVT MRI. Methods A single‐center cohort of consecutive acute stroke patients with anterior circulation large vessel occlusion, successful recanalization via EVT (mTICI ≥ 2b), and MRI of the brain between 12 hours and 7 days after EVT was evaluated. Imaging was processed via RAPID software. Final infarct volume was based on the traditional ADC

Introduction Endovascular therapy (EVT) has revolutionized acute stroke treatment, but large vessel recanalization does not always result in tissue‐level reperfusion. Cerebral blood flow (CBF) is not routinely monitored during EVT. Here we aimed to leverage diffuse correlation spectroscopy (DCS), a novel transcranial optical imaging technique, to assess the relationship between microvascular CBF and post‐EVT outcomes. Methods Frontal lobe CBF was monitored by DCS in 40 patients undergoing EVT. Baseline CBF deficit was calculated as the percentage of CBF impairment on pre‐EVT CT perfusion. Microvascular reperfusion was calculated as the percentage increase in DCS‐derived CBF that occurred with recanalization. The adequacy of reperfusion was defined by persistent CBF deficit, calculated as: baseline CBF deficit ‐ microvascular reperfusion. Good functional outcome was defined as 90‐day modified Rankin Scale ≤2. Results 36 (of 40) patients achieved successful recanalization, in whom microvascular reperfusion in itself was not associated with infarct volume or functional outcome. However, patients with good functional outcomes had a smaller persistent CBF deficit (median: 1%; IQR: ‐11%–16%) than patients with poor outcomes (median: 28%; IQR: 2%–50%), p=0.02. Smaller persistent CBF deficit was also associated with smaller infarct volume (p=0.004). Multivariate models confirmed that persistent CBF deficit was independently associated with infarct volume and functional outcome. Conclusion CBF augmentation alone does not predict post‐EVT outcomes, but when microvascular reperfusion closely matches the baseline CBF deficit, patients experience favorable clinical and radiographic outcomes. By recognizing inadequate reperfusion, bedside CBF monitoring may provide opportunities to personalize post‐EVT care aimed at CBF optimization.

Background Cardiovascular complications after acute ischemic stroke (AIS) can be related to chronic/comorbid cardiac conditions or acute disruption of the brain–heart autonomic axis (stroke‐heart syndrome). Women are known to be more vulnerable to certain stress‐induced cardiac complications, such as Takotsubo cardiomyopathy. We investigated sex differences in cardiac troponin (cTn) elevation, cardiac events, and outcomes after AIS. Methods and Results We retrospectively analyzed consecutive patients with AIS from 5 stroke centers. Patients with AIS with elevated baseline cTn and at least 2 cTn measurements were included, while patients with acute comorbid conditions that could impact cTn levels were excluded. Poststroke acute myocardial injury was defined as the presence of a dynamic cTn pattern (rise/fall >20% in serial measurements) in the absence of acute atherosclerotic coronary disease (type 1 myocardial infarction) or cardiac death (type 3 myocardial infarction). From a total cohort of 3789 patients with AIS, 300 patients were included in the study: 160 were women (53%). Women were older, had a lower burden of cardiovascular risk factors, and more frequently had cardioembolic stroke and right insula involvement (P values all

Abstract Background Insertable cardiac monitors (ICMs) are a clinically effective means of detecting atrial fibrillation (AF) in high-risk patients, and guiding the initiation of non-vitamin K oral anticoagulants (NOACs). Their cost-effectiveness from a US clinical payer perspective is not yet known. The objective of this study was to evaluate the cost-effectiveness of ICMs compared to standard of care (SoC) for detecting AF in patients at high risk of stroke (CHADS2 ≥ 2), in the US. Methods Using patient data from the REVEAL AF trial (n = 393, average CHADS2 score = 2.9), a Markov model estimated the lifetime costs and benefits of detecting AF with an ICM or with SoC (specifically intermittent use of electrocardiograms and 24-h Holter monitors). Ischemic and hemorrhagic strokes, intra- and extra-cranial hemorrhages, and minor bleeds were modelled. Diagnostic and device costs, costs of treating stroke and bleeding events and medical therapy—specifically costs of NOACs were included. Costs and health outcomes, measured as quality-adjusted life years (QALYs), were discounted at 3% per annum, in line with standard practice in the US setting. One-way deterministic and probabilistic sensitivity analyses (PSA) were undertaken. Results Lifetime per-patient cost for ICM was $31,116 versus $25,330 for SoC. ICMs generated a total of 7.75 QALYs versus 7.59 for SoC, with 34 fewer strokes projected per 1000 patients. The model estimates a number needed to treat of 29 per stroke avoided. The incremental cost-effectiveness ratio was $35,528 per QALY gained. ICMs were cost-effective in 75% of PSA simulations, using a $50,000 per QALY threshold, and a 100% probability of being cost-effective at a WTP threshold of $150,000 per QALY. Conclusions The use of ICMs to identify AF in a high-risk population is likely to be cost-effective in the US healthcare setting.

Background Results from multiple clinical trials support patent foramen ovale closure after cryptogenic stroke in select patients, but it remains unclear how new data and updated professional society guidelines have impacted clinical practice. Here, we aimed to compare how stroke neurologists and interventional cardiologists approach patients with cryptogenic stroke with patent foramen ovale and how critical anatomic and clinical factors influence decision making. Methods and Results An electronic survey was administered to 1556 vascular neurologists and 1057 interventional cardiologists throughout the United States. The survey addressed factors such as patient age, preclosure workup, and postclosure antithrombotics. Clinical vignettes highlighted critical variables and used a 5‐point Likert scale to assess the providers' level of support for closure. There were 491 survey responses received from 301 (of 1556) vascular neurologists and 190 (of 1057) interventional cardiologists, with an overall response rate of 19%. Vascular neurologists were more likely to recommend against closure on the basis of older age (P

Background Psychological health is as an important contributor to recovery after cardiovascular disease, but the roles of both optimism and depression in stroke recovery are not well characterized. Methods and Results A total of 879 participants in the SRUP (Stroke Recovery in Underserved Populations) 2005 to 2006 Study, aged ≥50 years, with incident stroke admitted to a rehabilitation facility were included. Optimism was assessed by the question: “Are you optimistic about the future?” Depression was defined by Center for Epidemiologic Studies Depression scale score >16. Participants were categorized into 4 groups: optimistic/without depression (n=581), optimistic/with depression (n=197), nonoptimistic/without depression (n=36), and nonoptimistic/with depression (n=65). Functional Independence Measure scores were used to assess stroke outcomes at discharge, 3 months after discharge, and 1 year after discharge with adjusted linear mixed models to estimate score trajectories. Participants were a mean age of 68 years (SD, 13 years), 52% were women, and 74% were White race. The optimistic/without depression group experienced the most recovery of total Functional Independence Measure scores in the first 3 months, 24.0 (95% CI, 22.5–25.4), followed by no change in the following 9 months, −0.3 (95% CI, −2.3 to 1.7), similar to the optimistic/with depression group with rapid recovery in 0 to 3 months, 21.1 (95% CI, 18.6–23.6) followed by minimal change in 3 to 12 months, 0.7 (95% CI, −2.8 to 4.1). The nonoptimistic groups demonstrated slow but continued recovery throughout the 12‐month period, with overall change, 25.4 (95% CI, 17.6–33.2) in the nonoptimistic/without depression group and 17.6 (95% CI, 12.0–23.1) in the nonoptimistic/with depression group. There was robust effect modification between optimism and depression (Pinteraction

Abstract Background The phase 2 PACE (Ponatinib Ph+ ALL and CML Evaluation) trial of ponatinib showed robust long-term benefit in relapsed Philadelphia chromosome-positive (Ph+) leukemia; arterial occlusive events (AOEs) occurred in ≥ 25% of patients based on investigator reporting. However, AOE rates vary depending on the definitions and reporting approach used. Methods To better understand clinically relevant AOEs with ponatinib, an independent cardiovascular adjudication committee reviewed 5-year AOE data from the PACE trial according to a charter-defined process and standardized event definitions. Results A total of 449 patients with chronic myeloid leukemia (CML) or Ph+ acute lymphoblastic leukemia (ALL) received ponatinib (median age 59 y; 47% female; 93% ≥ 2 prior tyrosine kinase inhibitors (TKIs); median follow-up, 37.3 months). The adjudicated AOE rate (17%) was lower than the non-adjudicated rate (i.e., rate before adjudication; 25%). The only adjudicated AOE in > 2% of patients was peripheral arterial occlusive disease (4%). Exposure-adjusted incidence of newly occurring adjudicated AOEs decreased over time. Patients with multiple baseline cardiovascular risk factors had higher adjudicated AOE rates than those without risk factors. Conclusions This independent adjudication study identified lower AOE rates than previously reported, suggesting earlier overestimation that may inaccurately reflect AOE risk with ponatinib. This trial was registered under ClinicalTrials.gov identifier NCT01207440 on September 23, 2010 ( https://clinicaltrials.gov/ct2/show/NCT01207440 ).

Background Early diagnosis is essential for effective stroke therapy. Strokes in hospitalized patients are associated with worse outcomes compared with strokes in the community. We derived and validated an algorithm to identify strokes by monitoring upper limb movements in hospitalized patients. Methods and Results A prospective case–control study in hospitalized patients evaluated bilateral arm accelerometry from patients with acute stroke with lateralized weakness and controls without stroke. We derived a stroke classifier algorithm from 123 controls and 77 acute stroke cases and then validated the performance in a separate cohort of 167 controls and 33 acute strokes, measuring false alarm rates in nonstroke controls and time to detection in stroke cases. Faster detection time was associated with more false alarms. With a median false alarm rate among nonstroke controls of 3.6 (interquartile range [IQR], 2.1–5.0) alarms per patient per day, the median time to detection was 15.0 (IQR, 8.0–73.5) minutes. A median false alarm rate of 1.1 (IQR. 0–2.2) per patient per day was associated with a median time to stroke detection of 29.0 (IQR, 11.0–58.0) minutes. There were no differences in algorithm performance for subgroups dichotomized by age, sex, race, handedness, nondominant hemisphere involvement, intensive care unit versus ward, or daytime versus nighttime. Conclusions Arm movement data can be used to detect asymmetry indicative of stroke in hospitalized patients with a low false alarm rate. Additional studies are needed to demonstrate clinical usefulness.

Background We hypothesized that stroke outcome is related to multiple baseline hydration‐related factors including volume contracted state (VCS) and diuretic use. Methods and Results We analyzed a prospective cohort of subjects with ischemic stroke

Background Endovascular therapy for acute ischemic stroke has revolutionized clinical care for patients with stroke and large vessel occlusion, but treatment remains time sensitive. At our stroke center, up to half of the door‐to‐groin time is accounted for after the patient arrives in the angio‐suite. Here, we apply the concept of a highly visible timer in the angio‐suite to quantify the impact on endovascular treatment time. Methods This was a single‐center prospective pseudorandomized study conducted over a 32‐week period. Pseudorandomization was achieved by turning the timer on and off in 2‐week intervals. The primary outcome was angio‐suite‐to‐groin time, and secondary outcomes were angio‐suite‐to‐intubation time, groin‐to‐recanalization time, and 90‐day modified Rankin scale. A stratified analysis was performed based on type of anesthesia (ie, endotracheal intubation versus not). Results During the 32‐week study period, 97 mechanical thrombectomies were performed. The timer was on and off for 38 and 59 cases, respectively. The timer resulted in faster angio‐suite‐to‐groin time (28 versus 33 minutes; P=0.02). The 5‐minute reduction in angio‐suite‐to‐groin was maintained after adjusting for intubation status in a multivariate regression (P=0.02). There was no difference in the 90‐day modified Rankin scale between groups. The timer impact was consistent across the 32‐week study period. Conclusions A highly visible timer in the angio‐suite achieved a meaningful, albeit modest, reduction in endovascular treatment time for patients with stroke. Given the lack of risk and low cost, it is reasonable for stroke centers to consider a highly visible timer in the angio‐suite to improve treatment times.

Background Acute endovascular revascularization for isolated internal carotid occlusion without tandem intracranial occlusion has been proposed to prevent early neurologic deterioration (END) and improve outcome, but has not been shown to be more effective than medical therapy. We aimed to evaluate prognosis with initial medical therapy alone, and also performed a systematic review to put these results in a broader context. Methods We performed a retrospective cohort study of patients admitted over a 2‐year period with acute stroke/transient ischemic attack due to isolated internal carotid artery occlusion. Subjects with tandem intracranial occlusion or Alberta Stroke Program Early CT Score (ASPECTS) ≤5 were excluded. The primary outcome was END within 48 hours (National Institute of Health Stroke Scale [NIHSS] increase ≥4 persisting for ≥24 hours). Secondary outcomes included discharge NIHSS and disposition. We also performed a systematic review and meta‐analysis of published studies along with the data from our cohort. Results Twenty‐three patients met our inclusion criteria. Median age was 69 years, initial Alberta Stroke Program Early CT Score 10, and NIHSS score 3. END attributed to recurrent ischemia occurred in 5/23 patients (22%, 95% CI: 7%–44%). At discharge, 78% had a favorable outcome with a median NIHSS of 2 (interquartile range 1–3). END appeared more frequent in those with higher baseline NIHSS. In our systematic review, 7 prior studies met our inclusion criteria. END occurred in 17% (95% CI: 12%–23%) of patients, 18% with medical therapy versus 13% with endovascular therapy, with substantial heterogeneity among studies. Conclusion In patients with acute stroke or transient ischemic attack due to isolated internal carotid occlusion, END is relatively common (occurring in about 1 out of 6 patients). Further research is needed to evaluate the roles of maximal medical management or acute endovascular thrombectomy in these patients.

Background Evidence from randomized trials and updated professional society guidelines supports patent foramen ovale (PFO) closure after cryptogenic stroke in select patients. It is unclear how this has been integrated into real‐world practice, so we aimed to compare practice patterns between cardiologists and neurologists. Methods and Results In March of 2021, a survey of cardiologists and neurologists who work or previously trained at the University of Pennsylvania Health System assessed practice preferences with respect to PFO closure after stroke. Clinical vignettes isolated specific variables of interest and used a 5‐point Likert scale to assess the level of support for PFO closure. Stroke neurologists and interventional cardiologists were compared by Wilcoxon‐Mann–Whitney tests. Secondarily, Kruskal–Wallis tests compared stroke neurologists, general neurologists, interventional cardiologists, and general cardiologists. We received 106 responses from 182 survey recipients (31/31 stroke neurologists, 38/46 interventional cardiologists, 20/30 general neurologists, and 17/77 general cardiologists). A similar proportion of stroke neurologists and interventional cardiologists favored PFO closure in a young patient with cryptogenic stroke, 88% and 87%, respectively (P=0.54). Interventionalists were more likely than stroke neurologists to support closure in the context of an alternative high‐risk stroke mechanism, 14% and 0%, respectively (P=0.003). Stroke neurologists were more likely to oppose closure on the basis of older age (P=0.01). Conclusions There are key differences between how neurologists and cardiologists approach PFO closure after stroke, particularly when interpreting the stroke etiology and when considering closure beyond the scope of prior trials; this underscores the importance of collaboration between cardiologists and neurologists.

Background The GWTG (Get With The Guidelines)‐Stroke registry supports clinical research and quality improvement projects that often rely on past medical history elements, the reliability of which remains largely unknown. Here, we evaluated the reliability of specific past medical history elements in a local GWTG–Stroke data set, with particular attention to calculating the CHA2DS2‐VASc score. Methods and Results A single‐center cohort was identified by querying the Hospital of the University of Pennsylvania’s GWTG IQVIA Registry Platform for patients admitted with acute ischemic stroke between January 2017 and December 2020, with a previously known history of atrial fibrillation. Demographics and previously known medical history elements were retrieved from the registry to calculate the CHA2DS2‐VASc score. Five neurologists abstracted the same medical history elements from the health records. The κ statistics quantified the reliability of medical history elements and CHA2DS2‐VASc score. Four hundred fifty‐three patients with acute ischemic stroke and previously known atrial fibrillation were included in the cohort. In comparison with manual reabstraction, registry‐based medical history elements were only moderately reliable: congestive heart failure (κ=0.53), hypertension (κ=0.42), diabetes (κ=0.80), prior stroke (κ=0.45), and vascular disease (κ=0.48). However, leveraging these variables to calculate the CHA2DS2‐VASc score was more reliable (κ=0.73). Conclusions Previously known medical history elements in the GWTG‐Stroke registry were only modestly reliable in this single‐center study, suggesting caution should be exercised when relying on any individual history elements in registry‐based research. Combining these variables to calculate the CHA2DS2‐VASc score was somewhat more reliable. Multicenter data are needed before assuming generalizability.

Abstract Background The cortical microvascular cerebral blood flow response (CBF) to different changes in head-of-bed (HOB) position has been shown to be altered in acute ischemic stroke (AIS) by diffuse correlation spectroscopy (DCS) technique. However, the relationship between these relative ΔCBF changes and associated systemic blood pressure changes has not been studied, even though blood pressure is a major driver of cerebral blood flow. Methods Transcranial DCS data from four studies measuring bilateral frontal microvascular cerebral blood flow in healthy controls (n = 15), patients with asymptomatic severe internal carotid artery stenosis (ICA, n = 27), and patients with acute ischemic stroke (AIS, n = 72) were aggregated. DCS-measured CBF was measured in response to a short head-of-bed (HOB) position manipulation protocol (supine/elevated/supine, 5 min at each position). In a sub-group (AIS, n = 26; ICA, n = 14; control, n = 15), mean arterial pressure (MAP) was measured dynamically during the protocol. Results After elevated positioning, DCS CBF returned to baseline supine values in controls (p = 0.890) but not in patients with AIS (9.6% [6.0,13.3], mean 95% CI, p

Background and Objectives: Warfarin and a skeletal muscle relaxant are co-treatments in nearly a quarter-million annual United States (US) office visits. Despite international calls to minimize patient harm arising from anticoagulant drug interactions, scant data exist on clinical outcomes in real-world populations. We examined effects of concomitant use of warfarin and individual muscle relaxants on rates of hospitalization for thromboembolism among economically disadvantaged persons. Materials and Methods: Using 1999–2012 administrative data of four US state Medicaid programs, we conducted 16 retrospective self-controlled case series studies: half included concomitant users of warfarin + one of eight muscle relaxants; half included concomitant users of an inhaled corticosteroid (ICS) + one of eight muscle relaxants. The ICS analyses served as negative control comparisons. In each study, we calculated incidence rate ratios (IRRs) comparing thromboembolism rates in the co-exposed versus warfarin/ICS-only exposed person-time, adjusting for time-varying confounders. Results: Among ~70 million persons, we identified 8693 warfarin-treated subjects who concomitantly used a muscle relaxant, were hospitalized for thromboembolism, and met all other inclusion criteria. Time-varying confounder-adjusted IRRs ranged from 0.31 (95% confidence interval: 0.13–0.77) for metaxalone to 3.44 (95% confidence interval: 1.53–7.78) for tizanidine. The tizanidine finding was robust after quantitatively adjusting for negative control ICS findings, and in numerous prespecified secondary analyses. Conclusions: We identified a potential >3-fold increase in the rate of hospitalized thromboembolism in concomitant users of warfarin + tizanidine vs. warfarin alone. Alternative explanations for this finding include confounding by indication, a native effect of tizanidine, or chance.

Abstract Background Stroke survivors are more physically inactive than even the most sedentary older adults, and low activity is associated with increased risk of recurrent stroke, medical complications, and mortality. We hypothesize that the combination of a fast walking intervention that improves walking capacity, with a step activity monitoring program that facilitates translation of gains from the clinic to the “real-world”, would generate greater improvements in real world walking activity than with either intervention alone. Methods Using a single-blind randomized controlled experimental design, 225 chronic (> 6 months) stroke survivors complete 12 weeks of fast walking training, a step activity monitoring program or a fast walking training + step activity monitoring program. Main eligibility criteria include: chronic ischemic or hemorrhagic stroke (> 6 months post), no evidence of cerebellar stroke, baseline walking speed between 0.3 m/s and 1.0 m/s, and baseline average steps / day

Background: Stroke patients are known to be at risk of developing anxiety, depression, and post-traumatic stress disorder (PTSD).Objective: To determine the overlap between anxiety, depression, and PTSD in patients after stroke and to determine the association between these disorders and quality of life, functional status, healthcare utilization, and return to work.Methods: A cross-sectional telephone survey was conducted to assess for depression, anxiety, PTSD, and health-related outcomes 6–12 months after first ischemic stroke in patients without prior psychiatric disease at a single stroke center.Results: Of 352 eligible subjects, 55 (16%) completed surveys. Seven subjects (13%) met criteria for probable anxiety, 6 (11%) for PTSD, and 11 for depression (20%). Of the 13 subjects (24%) who met criteria for any of these disorders, 6 (46%) met criteria for more than one, and 5 (39%) met criteria for all three. There were no significant differences in baseline characteristics, including stroke severity or neurologic symptoms, between those with or without any of these disorders. Those who had any of these disorders were less likely to be independent in their activities of daily living (ADLs) (54 vs. 95%, p < 0.001) and reported significantly worse quality of life (score of 0–100, median score of 50 vs. 80, p < 0.001) compared to those with none of these disorders.Conclusions: Anxiety, depression, and PTSD are common after stroke, have a high degree of co-occurrence, and are associated with worse outcomes, including quality of life and functional status.

ObjectiveThe objective of this study is to determine whether structural features of the vertebrobasilar arterial system are related to migraine.BackgroundAlterations in cerebral vascular structure and function have been associated with migraine, possibly mediated by hypoperfusion and/or endothelial dysfunction triggering cortical spreading depression. Vessel tortuosity, in particular, has been associated with both altered hemodynamics and endothelial function. Symptoms of migraine with aura (MWA) often localize to the occipital cortex, and evidence supports the localization of a migraine generator to the brain stem, suggesting that the vertebrobasilar system may be of particular relevance.MethodsWe performed a post hoc exploratory analysis of data collected in a prospective, observational, case-control study enrolling MWA, migraine without aura (MwoA), and control subjects in a 1:1:1 ratio. 3 T high-resolution MR angiography was used to assess vascular structure, and arterial spin-labeled perfusion MRI to measure interictal cerebral blood flow (CBF). White matter lesions were assessed using T2/FLAIR. Vertebral and basilar artery (BA) diameters and BA total lateral displacement were measured.Results162 subjects were included (52 control/52 MWA/58 MwoA). Mean age was 33 ± 6 years, and 78% were female. BA diameter was similar across groups (3.6 ± 0.6 mm in all 3 groups). BA displacement was similar in MwoA (5.1 ± 3.0 mm) and controls (4.9 ± 3.1 mm), but tended to be greater in MWA (6.3 ± 3.8 mm, p = 0.055 vs. controls). BA displacement increased with age (p

Background. Cervicocephalic arterial dissection (CCAD) is rare in the postpartum period. To our knowledge this is the first reported case of postpartum angiopathy (PPA) presenting with ischemic stroke due to intracranial arterial dissection. Case. A 41-year-old woman presented with blurred vision, headache, and generalized seizures 5 days after delivering twins. She was treated with magnesium for eclampsia. MRI identified multiple posterior circulation infarcts. Angiography identified a complex dissection extending from both intradural vertebral arteries, through the basilar artery, and into both posterior cerebral arteries. Multiple segments of arterial dilatation and narrowing consistent with PPA were present. Xenon enhanced CT (Xe-CT) showed reduced regional cerebral blood flow that is improved with elevation in blood pressure. Conclusion. Intracranial vertebrobasilar dissection causing stroke is a rare complication of pregnancy. Eclampsia and PPA may play a role in its pathogenesis. Blood pressure management may be tailored using quantitative blood flow studies, such as Xe-CT.