Optimal Timing for Resumption of Anticoagulation After Intracranial Hemorrhage in Patients With Mechanical Heart Valves

BACKGROUND

Anticoagulation in patients with intracranial hemorrhage (ICH) and mechanical heart valves is often held for risk of ICH expansion; however, there exists a competing risk of acute ischemic stroke (AIS). Optimal timing to resume anticoagulation remains uncertain.

METHODS AND RESULTS

We retrospectively studied patients with ICH and mechanical heart valves from 2000 to 2018. The primary outcome was a composite end point of symptomatic hematoma expansion or new ICH, AIS, and intracardiac thrombus up to 30 days post-ICH. The exposure was timing of reinitiation of anticoagulation classified as early (resumed up to 7 days after ICH), late (≥7 and up to 30 days after ICH), and never if not resumed or resumed after 30 days post-ICH. We included 184 patients with ICH and mechanical heart valves (65 anticoagulated early, 100 late, 19 not resumed by day 30 post-ICH). Twelve patients had AIS, 16 new ICH, and 6 intracardiac thromboses. The mean time from ICH to anticoagulation was 12.7 days. Composite outcomes occurred in 12 patients resumed early (18.5%), 14 resumed late (14.0%), and 4 never resumed (21.1%). There was no increased hazard of the composite outcome (hazard ratio [HR], 1.1 [95% CI, 0.2-6.0]), AIS, or worsening or new ICH among patients resumed early versus late. There was no difference in the composite among patients never resumed versus resumed. Patients who never resumed anticoagulation had significantly more severe ICH (median Glasgow Coma Scale: 10.6, 13.9, and 13.9 among those who resumed never, early, and late, respectively; P=0.0001), higher in-hospital mortality (56.5%, 0%, and 0%, respectively; P<0.0001), and an elevated 30-day AIS risk (HR, 15.9 [95% CI, 1.9-129.7], P=0.0098).

CONCLUSIONS

In this study of patients with ICH and mechanical heart valves, there was no difference in 30-day thrombotic and hemorrhagic brain-related outcomes when anticoagulation was resumed within 7 versus 7 to 30 days after ICH. Withholding anticoagulation >30 days was associated with severe baseline ICH, higher in-hospital case fatality, and elevated AIS risk.

Baseline characteristics and outcome of stroke patients after endovascular therapy according to previous symptomatic vascular disease and sex

Aim

The aim of this study was to investigate baseline characteristics and outcome of patients after endovascular therapy (EVT) for acute large vessel occlusion (LVO) in relation to their history of symptomatic vascular disease and sex.

Methods

Consecutive EVT-eligible patients with LVO in the anterior circulation admitted to our stroke center between 04/2015 and 04/2020 were included in this observational cohort study. All patients were treated according to a standardized acute ischaemic stroke (AIS) protocol. Baseline characteristics and successful reperfusion, recurrent/progressive in-hospital ischaemic stroke, symptomatic in-hospital intracranial hemorrhage, death at discharge and at 3 months, and functional outcome at 3 months were analyzed according to previous symptomatic vascular disease and sex.

Results

995 patients with LVO in the anterior circulation (49.4% women, median age 76 years, median admission NIHSS score 14) were included. Patients with multiple vs. no previous vascular events showed higher mortality at discharge (20% vs. 9.3%, age/sex - adjustedOR = 1.43, p = 0.030) and less independency at 3 months (28.8% vs. 48.8%, age/sex - adjustedOR = 0.72, p = 0.020). All patients and men alone with one or multiple vs. patients and men with no previous vascular events showed more recurrent/progressive in-hospital ischaemic strokes (19.9% vs. 6.4% in all patients, age/sex - adjustedOR = 1.76, p = 0.028) (16.7% vs. 5.8% in men, age-adjustedOR = 2.20, p = 0.035). Men vs. women showed more in-hospital symptomatic intracranial hemorrhage among patients with one or multiple vs. no previous vascular events (23.7% vs. 6.6% in men and 15.4% vs. 5.5% in women, OR = 2.32, p = 0.035/age - adjustedOR = 2.36, p = 0.035).

Conclusions

Previous vascular events increased the risk of in-hospital complications and poorer outcome in the analyzed patients with EVT-eligible LVO-AIS. Our findings may support risk assessment in these stroke patients and could contribute to the design of future studies.

Thrombolytic Treatment in Wake-Up Stroke: A Propensity Score-Matched Analysis of Treatment Effectiveness in the Norwegian Stroke Registry

BACKGROUND

Previous clinical trials found improved outcome of thrombolytic treatment in patients with ischemic wake-up stroke (WUS) selected by advanced imaging techniques. The authors assessed the effectiveness of thrombolytic treatment in patients with WUS in a nationwide stroke registry.

METHODS AND RESULTS

Using propensity score matching, the authors assessed the effectiveness and safety of thrombolytic treatment versus no thrombolytic treatment in 726 patients (363 matched pairs) with WUS in the Norwegian Stroke Registry in 2014 to 2019. Thrombolytic treatment in WUS versus known-onset stroke was compared in 730 patients (365 matched pairs). Functional outcomes were assessed by the modified Rankin Scale (mRS) at 3 months. A significant benefit of thrombolytic treatment in WUS was seen in ordinal analysis (odds ratio [OR], 1.48 [95% CI, 1.15-1.91]; P=0.003) and for mRS 0 to 2 (OR, 1.81 [95% CI, 1.29-2.52]; P=0.001) but not for mRS 0 or 1 (OR, 1.32 [95% CI, 1.00-1.74]; P=0.050). The proportion of patients with mRS 0 or 1 was lower in patients with WUS who underwent thrombolysis versus those with known-onset stroke (50.4% versus 59.5%; OR, 0.69 [95% CI, 0.52-0.93]; P=0.013), while outcomes were similar between groups for mRS 0 to 2 and ordinal analysis. Symptomatic intracranial hemorrhage after thrombolytic treatment occurred in 4.4% of patients with WUS and 3.9% of patients with known-onset stroke (OR, 1.14 [95% CI, 0.54-2.41]; P=0.726).

CONCLUSIONS

Thrombolytic treatment in patients with WUS was associated with improved functional outcome compared with patients with no thrombolytic treatment and was not associated with increased rates of symptomatic intracranial hemorrhage compared with known-onset stroke. The results indicate that thrombolytic treatment is effective and safe in WUS in a real-life setting.

Corrigendum: Staged use of ordinal and linear disability scales: a practical approach to granular assessment of acute stroke outcome

[This corrects the article DOI: 10.3389/fneur.2023.1174686.].

Staged use of ordinal and linear disability scales: a practical approach to granular assessment of acute stroke outcome

Background

The modified Rankin Scale (mRS) assessment of global disability is the most common primary endpoint in acute stroke trials but lacks granularity (7 broad levels) and is ordinal (scale levels unknown distances apart), which constrains study power. Disability scales that are linear and continuous may better discriminate outcomes, but computerized administration in stroke patients is challenging. We, therefore, undertook to develop a staged use of an ordinal followed by a linear scale practical to use in multicenter trials.

Methods

Consecutive patients undergoing 3-month final visits in the NIH FAST-MAG phase 3 trial were assessed with the mRS followed by 15 mRS level-specific yes-no items of the Academic Medical Center Linear Disability Score (ALDS), a linear disability scale derived using item response theory.

Results

Among 55 patients, aged 71.2 (SD ± 14.2), 67% were men and the entry NIHSS was 10.7 (SD ± 9.5). At 90 days, the median mRS score was 3 (IQR, 1-4), and the median ALDS score was 78.8 (IQR, 3.3-100). ALDS scores correlated strongly with 90 days outcome measures, including the Barthel Index (r = 0.92), NIHSS (r = 0.87), and mRS (r = 0.94). ALDS scores also correlated modestly with entry NIHSS (r = 0.38). At 90 days, the ALDS showed greater scale granularity than the mRS, with fewer patients with identical values, 1.9 (SD ± 3.2) vs. 8.0 (SD ± 3.6), p < 0.001. When treatment effect magnitudes were small to moderate, projected trial sample size requirements were 2-12-fold lower when the ALDS rather than the mRS was used as the primary trial endpoint.

Conclusion

Among patients enrolled in an acute neuroprotective stroke trial, the ALDS showed strong convergent validity and superior discrimination characteristics compared with the modified Rankin Scale and increased projected trial power to detect clinically meaningful treatment benefits.

Patterns and Outcomes of Intensive Care on Acute Ischemic Stroke Patients in the US

BACKGROUND

Up to 20% of acute ischemic stroke (AIS) patients may benefit from intensive care unit (ICU)-level care; however, there are few studies evaluating ICU availability for AIS. We aim to summarize the proportion of elderly AIS patients in the United States who are admitted to an ICU and assess the national availability of ICU-level care in AIS.

METHODS

We performed a retrospective cohort study using de-identified Medicare inpatient datasets from January 1, 2016 through December 31, 2019 for US individuals aged ≥65 years. We used validated International Classification of Diseases, Tenth Revision, Clinical Modification codes to identify AIS admission and interventions. ICU-level care was identified by revenue center code. AIS patient characteristics and interventions were stratified by receipt of ICU-level care, comparing differences through calculated standardized mean difference score due to large sample sizes.

RESULTS

From 2016 through 2019, a total of 952 400 admissions by 850 055 individuals met criteria for hospital admission for AIS with 19.9% involving ICU-level care. Individuals were predominantly >75 years of age (58.5%) and identified as white (80.0%). Hospitals on average admitted 11.4% (SD 14.6) of AIS patients to the ICU, with the median hospital admitting 7.7% of AIS patients to the ICU. The ICU admissions were younger and more likely to receive reperfusion therapy but had more comorbid conditions and neurologic complications. Of the 5084 hospitals included, 1971 (38.8%) reported no ICU-level AIS care. Teaching hospitals (36.9% versus 1.6%, P<0.0001) with larger AIS volume (P<0.0001) or in larger metropolitan areas (P<0.0001) were more likely to have an ICU available.

CONCLUSIONS

We found evidence of national variation in the availability of ICU-level care for AIS admissions. Since ICUs may provide comprehensive care for the most severe AIS patients, continued effort is needed to examine ICU accessibility and utility among AIS.

Role of Renin-Angiotensin-Aldosterone System Inhibition in Patients Undergoing Carotid Revascularization

Background

Previous data suggest that using renin‐angiotensin‐aldosterone system inhibitors (RAASIs) improves survival in patients with cardiovascular diseases. We sought to investigate the association of different patterns of use of RAASIs on perioperative and 1‐year outcomes following carotid revascularization.

Methods and Results

We investigated patients undergoing carotid revascularization, either with carotid endarterectomy or transfemoral carotid artery stenting, in the VQI (Vascular Quality Initiative) VISION (Vascular Implant Surveillance and Interventional Outcomes Network) data set between 2003 and 2018. We divided our cohort into 3 groups: (1) no history of RAASI intake, (2) preoperative intake only, and (3) continuous pre‐ and postoperative intake. The final cohort included 73 174 patients; 44.4% had no intake, 50% had continuous intake, and 5.6% had only preoperative intake. Compared with continuous intake, preoperative and no intake were associated with higher odds of postoperative stroke (odds ratio [OR], 1.7 [95% CI, 1.5–1.9]; P<0.001; OR, 1.1 [95% CI, 1.03–1.2]; P=0.010); death (OR, 4.8 [95% CI, 3.8–6.1]; P<0.001; OR, 1.9 [95% CI, 1.6–2.2]; P<0.001); and stroke/death (OR, 2.05 [95% CI, 1.8–2.3]; P<0.001; OR, 1.2 [95% CI, 1.1–1.3]; P<0.001), respectively. At 1 year, preoperative and no intake were associated with higher odds of stroke (hazard ratio [HR], 1.4 [95% CI, 1.3–1.6]; P<0.001; HR, 1.15, [95% CI, 1.08–1.2]; P<0.001); death (HR, 1.7 [95% CI, 1.5–1.9]; P<0.001; HR, 1.3 [95% CI, 1.2–1.4]; P<0.001); and stroke/death (HR, 1.5 [95% CI, 1.4–1.7]; P<0.001; HR, 1.2 [95% CI, 1.17–1.3]; P<0.001), respectively.

Conclusions

Compared with subjects discontinuing or never starting RAASIs, use of RAASIs before and after carotid revascularization was associated with a short‐term stroke and mortality benefit. Future clinical trials examining prescribing patterns of RAASIs should aim to clarify the timing and potential to maximize the protective effects of RAASIs in high‐risk vascular patients.

Aspiration Versus Stent Retriever Thrombectomy for Distal, Medium Vessel Occlusion Stroke in the Posterior Circulation: A Subanalysis of the TOPMOST Study

BACKGROUND

The optimal endovascular strategy for reperfusing distal medium-vessel occlusions (DMVO) remains unknown. This study evaluates angiographic and clinical outcomes of thrombectomy strategies in DMVO stroke of the posterior circulation.

METHODS

TOPMOST (Treatment for Primary Medium Vessel Occlusion Stroke) is an international, retrospective, multicenter, observational registry of patients treated for DMVO between January 2014 and June 2020. This study analyzed endovascularly treated isolated primary DMVO of the posterior cerebral artery in the P2 and P3 segment. Technical feasibility was evaluated with the first-pass effect defined as a modified Thrombolysis in Cerebral Infarction Scale score of 3. Rates of early neurological improvement and functional modified Rankin Scale scores at 90 days were compared. Safety was assessed by the occurrence of symptomatic intracranial hemorrhage and intervention-related serious adverse events.

RESULTS

A total of 141 patients met the inclusion criteria and were treated endovascularly for primary isolated DMVO in the P2 (84.4%, 119) or P3 segment (15.6%, 22) of the posterior cerebral artery. The median age was 75 (IQR, 62-81), and 45.4% (64) were female. The initial reperfusion strategy was aspiration only in 29% (41) and stent retriever in 71% (100), both achieving similar first-pass effect rates of 53.7% (22) and 44% (44; P=0.297), respectively. There were no significant differences in early neurological improvement (aspiration: 64.7% versus stent retriever: 52.2%; P=0.933) and modified Rankin Scale rates (modified Rankin Scale score 0-1, aspiration: 60.5% versus stent retriever 68.6%; P=0.4). In multivariable logistic regression analysis, the time from groin puncture to recanalization was associated with the first-pass effect (adjusted odds ratio, 0.97 [95% CI, 0.95-0.99]; P<0.001) that in turn was associated with early neurological improvement (aOR, 3.27 [95% CI, 1.16-9.21]; P<0.025). Symptomatic intracranial hemorrhage occurred in 2.8% (4) of all cases.

CONCLUSIONS

Both first-pass aspiration and stent retriever thrombectomy for primary isolated posterior circulation DMVO seem to be safe and technically feasible leading to similar favorable rates of angiographic and clinical outcome.

Carotid Atheroinflammation Is Associated With Cerebral Small Vessel Disease Severity

Background: Atherosclerosis is a systemic inflammatory disease, with common inflammatory processes implicated in both atheroma vulnerability and blood-brain barrier disruption. This prospective multimodal imaging study aimed to measure directly the association between systemic atheroma inflammation (“atheroinflammation”) and downstream chronic cerebral small vessel disease severity.

Methods: Twenty-six individuals with ischemic stroke with ipsilateral carotid artery stenosis of >50% underwent ¹⁸fluoride-fluorodeoxyglucose-positron emission tomography within 2 weeks of stroke. Small vessel disease severity and white matter hyperintensity volume were assessed using 3-tesla magnetic resonance imaging also within 2 weeks of stroke.

Results: Fluorodeoxyglucose uptake was independently associated with more severe small vessel disease (odds ratio 6.18, 95% confidence interval 2.1–18.2, P < 0.01 for the non-culprit carotid artery) and larger white matter hyperintensity volumes (coefficient = 14.33 mL, P < 0.01 for the non-culprit carotid artery).

Conclusion: These proof-of-concept results have important implications for our understanding of the neurovascular interface and potential therapeutic exploitation in the management of systemic atherosclerosis, particularly non-stenotic disease previously considered asymptomatic, in order to reduce the burden of chronic cerebrovascular disease.

Atrial fibrosis in embolic stroke of undetermined source: A multicenter study

BACKGROUND AND PURPOSE

Left atrial (LA) cardiac disease is a suspected cause of embolic stroke of undetermined source (ESUS). We tested the hypothesis that LA fibrosis, quantified using late-gadolinium-enhancement magnetic resonance imaging (LGE-MRI), predicts recurrent stroke or atrial fibrillation (AF) in patients with ESUS.

METHODS

We compared atrial fibrosis in healthy controls and patients with lacunar stroke, ESUS, and known AF with or without prior stroke. We followed patients with ESUS prospectively for the primary outcome of recurrent ischemic stroke, incident AF, or both.

RESULTS

We enrolled 203 patients from three centers: 103 patients without AF (35 healthy controls, 15 with lacunar strokes, 53 with ESUS) and 100 patients with AF (50 with and 50 without prior stroke). Patients with ESUS had significantly higher atrial fibrosis (15.0 ± 6.2%) compared to healthy controls (8.1 ± 7.9%; <0.0001) and compared to lacunar stroke patients (10.8 ± 8.4; p = 0.02), but had comparable fibrosis to patients with AF with (17.9 ± 11.4%) or without prior stroke (16.6 ± 9.2%; p = NS for both). Over a mean follow-up of 19 months, nine of 53 patients (16.9%) with ESUS experienced the combined primary outcome, which included six patients (11.3%) with recurrent ischemic stroke and five patients with incident AF (9.4%). Patients with ESUS with fibrosis ≥12% had a higher proportion of the combined outcome: 25.0% vs. 4.8%; p = 0.039.

CONCLUSIONS

Patients with ESUS demonstrate atrial fibrosis comparable to that seen in AF. Atrial fibrosis ≥12% was associated with recurrent stroke, incident AF or both. This subgroup of ESUS patients may benefit from anticoagulation for secondary prevention of ischemic stroke.

Automated prediction of final infarct volume in patients with large-vessel occlusion acute ischemic stroke

OBJECTIVE

In patients with large-vessel occlusion (LVO) acute ischemic stroke (AIS), determinations of infarct size play a key role in the identification of candidates for endovascular stroke therapy (EVT). An accurate, automated method to quantify infarct at the time of presentation using widely available imaging modalities would improve screening for EVT. Here, the authors aimed to compare the performance of three measures of infarct core at presentation, including an automated method using machine learning.

METHODS

Patients with LVO AIS who underwent successful EVT at four comprehensive stroke centers were identified. Patients were included if they underwent concurrent noncontrast head CT (NCHCT), CT angiography (CTA), and CT perfusion (CTP) with Rapid imaging at the time of presentation, and MRI 24 to 48 hours after reperfusion. NCHCT scans were analyzed using the Alberta Stroke Program Early CT Score (ASPECTS) graded by neuroradiology or neurology expert readers. CTA source images were analyzed using a previously described machine learning model named DeepSymNet (DSN). Final infarct volume (FIV) was determined from diffusion-weighted MRI sequences using manual segmentation. The primary outcome was the performance of the three infarct core measurements (NCHCT-ASPECTS, CTA with DSN, and CTP-Rapid) to predict FIV, which was measured using area under the receiver operating characteristic (ROC) curve (AUC) analysis.

RESULTS

Among 76 patients with LVO AIS who underwent EVT and met inclusion criteria, the median age was 67 years (IQR 54-76 years), 45% were female, and 37% were White. The median National Institutes of Health Stroke Scale score was 16 (IQR 12-22), and the median NCHCT-ASPECTS on presentation was 8 (IQR 7-8). The median time between when the patient was last known to be well and arrival was 156 minutes (IQR 73-303 minutes), and between NCHCT/CTA/CTP to groin puncture was 73 minutes (IQR 54-81 minutes). The AUC was obtained at three different cutoff points: 10 ml, 30 ml, and 50 ml FIV. At the 50-ml FIV cutoff, the AUC of ASPECTS was 0.74; of CTP core volume, 0.72; and of DSN, 0.82. Differences in AUCs for the three predictors were not significant for the three FIV cutoffs.

CONCLUSIONS

In a cohort of patients with LVO AIS in whom reperfusion was achieved, determinations of infarct core at presentation by NCHCT-ASPECTS and a machine learning model analyzing CTA source images were equivalent to CTP in predicting FIV. These findings have suggested that the information to accurately predict infarct core in patients with LVO AIS was present in conventional imaging modalities (NCHCT and CTA) and accessible by machine learning methods.

Progress Toward Achieving National Targets for Reducing Coronary Heart Disease and Stroke Mortality: A County-Level Perspective

Background

The American Heart Association and Healthy People 2020 established objectives to reduce coronary heart disease (CHD) and stroke death rates by 20% by the year 2020, with 2007 as the baseline year. We examined county‐level achievement of the targeted reduction in CHD and stroke death rates from 2007 to 2017.

Methods and Results

Applying a hierarchical Bayesian model to National Vital Statistics data, we estimated annual age‐standardized county‐level death rates and the corresponding percentage change during 2007 to 2017 for those aged 35 to 64 and ≥65 years and by urban‐rural classification. For those aged ≥35 years, 56.1% (95% credible interval [CI], 54.1%–57.7%) and 39.8% (95% CI, 36.9%–42.7%) of counties achieved a 20% reduction in CHD and stroke death rates, respectively. For both CHD and stroke, the proportions of counties achieving a 20% reduction were lower for those aged 35 to 64 years than for those aged ≥65 years (CHD: 32.2% [95% CI, 29.4%–35.6%] and 64.1% [95% CI, 62.3%–65.7%]), respectively; stroke: 17.9% [95% CI, 13.9%–22.2%] and 45.6% [95% CI, 42.8%–48.3%]). Counties achieving a 20% reduction in death rates were more commonly urban counties (except stroke death rates for those aged ≥65 years).

Conclusions

Our analysis found substantial, but uneven, achievement of the targeted 20% reduction in CHD and stroke death rates, defined by the American Heart Association and Healthy People. The large proportion of counties not achieving the targeted reduction suggests a renewed focus on CHD and stroke prevention and treatment, especially among younger adults living outside of urban centers. These county‐level patterns provide a foundation for robust responses by clinicians, public health professionals, and communities.

Activation of Glutamate Transporter-1 (GLT-1) Confers Sex-Dependent Neuroprotection in Brain Ischemia

Stroke is one of the leading causes of long-term disability. During ischemic stroke, glutamate is released, reuptake processes are impaired, and glutamate promotes excitotoxic neuronal death. Astrocytic glutamate transporter 1 (GLT-1) is the major transporter responsible for removing excess glutamate from the extracellular space. A translational activator of GLT-1, LDN/OSU 0212320 (LDN) has been previously developed with beneficial outcomes in epileptic animal models but has never been tested as a potential therapeutic for ischemic strokes. The present study evaluated the effects of LDN on stroke-associated brain injury. Male and female mice received LDN or vehicle 24 h before or 2 h after focal ischemia was induced in the sensorimotor cortex. Sensorimotor performance was determined using the Rung Ladder Walk and infarct area was assessed using triphenyltetrazolium chloride staining. Males treated with LDN exhibited upregulated GLT-1 protein levels, significantly smaller infarct size, and displayed better sensorimotor performance in comparison to those treated with vehicle only. In contrast, there was no upregulation of GLT-1 protein levels and no difference in infarct size or sensorimotor performance between vehicle- and LDN-treated females. Taken together, our results indicate that the GLT-1 translational activator LDN improved stroke outcomes in young adult male, but not female mice.

The Anatomy of the Circle of Willis Is Not a Strong Enough Predictive Factor for the Prognosis of Cross-Clamping Intolerance during Carotid Endarterectomy

Carotid endarterectomy (CEA) is safe and effective in reducing the risk of stroke in symptomatic severe carotid artery stenosis. Having information about cross-clamping (CC) intolerance before surgery may reduce the complication rate. The purpose of this study was to assess the usefulness of magnetic resonance angiography (MRA) and magnetic resonance angiography perfusion (P-MR) in determining the risk of CC intolerance during CEA. Material and methods: 40 patients after CEA with CC intolerance were included in Group I, and 15 with CC tolerance in Group II. All patients underwent MRA of the circle of Willis (CoW), P-MR with or without Acetazolamide; P(A)-MR in the postoperative period. Results: CoW was normal in the MRA in three cases (7.5%) in Group I, and in eight (53%) in Group II. We found P-MR abnormalities in all patients from Group I and in 40% from Group II. Using a calculated cut-off point of 0.322, the patients were classified as CC tolerant with 100% sensitivity or as CC intolerant with 95% specificity. After evaluating P-MR or MRA alone, the percentage of false negative results significantly increased. Conclusion: The highest value in predicting cross-clamping intolerance is achieved by using analysis of P(A)-MR and MRA of the CoW in combination.

Using artificial intelligence for improving stroke diagnosis in emergency departments: a practical framework

Stroke is the fifth leading cause of death in the United States and a major cause of severe disability worldwide. Yet, recognizing the signs of stroke in an acute setting is still challenging and leads to loss of opportunity to intervene, given the narrow therapeutic window. A decision support system using artificial intelligence (AI) and clinical data from electronic health records combined with patients' presenting symptoms can be designed to support emergency department providers in stroke diagnosis and subsequently reduce the treatment delay. In this article, we present a practical framework to develop a decision support system using AI by reflecting on the various stages, which could eventually improve patient care and outcome. We also discuss the technical, operational, and ethical challenges of the process.

Retrospective collection of 90-day modified Rankin Scale is accurate

BACKGROUND

The 90-day modified Rankin Scale is a widely used outcome after stroke but is sometimes hard to ascertain due to loss to follow-up. Missing outcomes can result in biased and/or inefficient estimates in clinical trials. The aim of this study is to assess the validity of acquiring the 90-day modified Rankin Scale at a later point of time when the patient has been lost at 90 days to impute the missing value.

METHODS

Participants who had prospectively completed a 90-day modified Rankin Scale questionnaire on their own in the Benefits of Stroke Treatment Using a Mobile Stroke Unit study were randomly interviewed to recall the 90-day modified Rankin Scale at 6, 9, or 12 months after hospital discharge over the phone. Concordance between the two scores was assessed using kappa and weighted kappa statistics. Logistic regression was used to identify factors associated with inconsistent reporting of the 90-day modified Rankin Scale.

RESULTS

Substantial agreement was observed between in-the-moment and retrospective 90-day modified Rankin Scale recalled at 6, 9, or 12 months (weighted kappa = 0.93, 95% confidence interval: 0.89-0.98; weighted kappa = 0.93, 95% confidence interval: 0.85-1.00 and weighted kappa = 0.89, 95% confidence interval: 0.82-0.95, respectively).

CONCLUSION

Retrospective recall of 90-day modified Rankin Scale at a later time point is a valid means to impute missing data in stroke clinical trials.

Coronavirus Disease 2019 and the Cerebrovascular-Cardiovascular Systems: What Do We Know So Far?

The severe acute respiratory syndrome coronavirus 2 pandemic of 2019 to 2020 has resulted in multiple hospitalizations, deaths, and economic hardships worldwide. Although respiratory involvement in patients with coronavirus disease 2019 (COVID-19) is well known, the potential cardiovascular and cerebrovascular manifestations are less understood. We performed a PubMed and Google Scholar search and reviewed relevant literature on COVID-19 and cardiovascular system involvement. Severe acute respiratory syndrome coronavirus 2 possesses high affinity for angiotensin-converting enzyme 2 receptor, which is highly concentrated in the lungs and cardiovascular tissue, thereby provoking concern for cardiovascular involvement in COVID-19 cases. Preexisting cardiovascular and cerebrovascular disease has been shown in previous reports to be a risk factor for severe infection. On the basis of our review of published studies, COVID-19 patients may be more likely to experience acute cardiac injury, arrhythmia, coagulation defects, and acute stroke and are likely to have poorer outcomes as a result. As the COVID-19 pandemic continues, more data about potential cardiovascular and cerebrovascular manifestations of the disease are required.

Effect of Balloon Guide Catheter Utilization on the Incidence of Sub-angiographic Peripheral Emboli on High-Resolution DWI After Thrombectomy: A Prospective Observational Study

Background: Thrombus fragmentation causing distal emboli is a feared complication during mechanical thrombectomy (MT). We aimed to investigate the impact of procedural parameters and thrombus properties on the incidence of peripheral emboli after MT for large vessel occlusions (LVO).

Methods: We performed a prospective analysis of patients with LVO stroke successfully treated with MT, defined as a score of 2b, 2c, or 3 on the thrombolysis in cerebral infarction (TICI) scale. A follow-up MRI including high-resolution diffusion-weighted imaging (DWI) was performed within 24 h following MT. The primary endpoint was the number and volume of peripheral emboli, classified as punctuate DWI lesions distant to the diffusion-restricted core lesion. Further analysis included the influence of baseline characteristics, procedural and outcome parameters, and thrombus properties on peripheral emboli.

Results: Thirty-seven patients with successful MT met the inclusion criteria. Use of a balloon guide catheter (BGC) and TICI were the only independent predictors for a reduced number of peripheral emboli. The use of a BGC led to a significant reduction in the number and volume of peripheral emboli, with a median number/volume of peripheral emboli of 4.5/287 μl (IQR 1.25–8.25/76–569 μl) vs. 12/938 μl (IQR 4–19/242–1,836 μl). In cases where BGC was not employed, the number of peripheral emboli increased with decreasing TICI scores.

Conclusions: BGC-aided MT reduces the number of peripheral emboli in successful but incomplete reperfusion (TICI 2b and 2c). The effectiveness of this strategy therefore goes above and beyond that which can be demonstrated by the TICI score alone.

Using Routinely Gathered Clinical Data to Develop a Prognostic Online Tool for Decannulation in Subjects With Acquired Brain Injury

BACKGROUND

Clinicians are often required to provide a qualified guess on the probability of decannulation in estimating patients' rehabilitation potential and relaying information about prognosis to patients and next of kin. The objective of this study was to use routinely gathered clinical data to develop a prognostic model of time to decannulation in subjects with acquired brain injury, for direct implementation in clinical practice.

METHODS

Data from a large cohort including 574 tracheostomized subjects admitted for neurorehabilitation were analyzed using discrete time-to-event analysis with logit-link. Within this model, a reference hazard function was modeled using restricted cubic splines, and estimates were presented using odds ratios (95% CIs).

RESULTS

A total of 411 subjects (72%) were decannulated within a median of 27 d (interquartile range 16-49) at the rehabilitation hospital. The prognostic model for decannulation included age, diagnosis, days from injury until admission for rehabilitation, swallowing, and overall functional level measured with the Early Functional Abilities score. Among these, the strongest predictors for decannulation were age and a combination of overall functional abilities combined with swallowing ability.

CONCLUSIONS

A prognostic model for decannulation was developed using routinely gathered clinical data. Based on the model, an online graphical user interface was applied, in which the probability of decannulation within x days is calculated along with the statistical uncertainty of the probability. Furthermore, a layman's interpretation is provided. The online tool was directly implemented in clinical practice at the rehabilitation hospital, and is available through this link: (http://www.hospitalsenhedmidt.dk/regionshospitalet-hammel/research-unit/Prognosissoftware/).

The Cincinnati Prehospital Stroke Scale Compared to Stroke Severity Tools for Large Vessel Occlusion Stroke Prediction

BACKGROUND

Various screening tools, ranging in complexity, have been developed to predict large vessel occlusion (LVO) stroke in the prehospital setting. Our objective was to determine whether newly-developed LVO stroke scales offer a clinically-meaningful advantage over the Cincinnati Prehospital Stroke Scale (CPSS).

METHODS

We retrospectively analyzed prehospital patient care records linked with hospital data from 151 EMS agencies in the United States, between January 1, 2018 and December 31, 2018. We compared the CPSS to the Rapid Arterial Occlusion Evaluation (RACE), Los Angeles Motor Scale (LAMS), and the Vision, Aphasia, Neglect (VAN) assessment for LVO prediction. For each stroke scale, we used the intersection of sensitivity and specificity curves to determine optimal prediction cut-points. We used area under the ROC curve and 95% confidence intervals to assess for differences in discriminative ability between scales.

RESULTS

We identified 13,596 prehospital records with one or more documented stroke scales of interest. Among these, 4,228 patients were diagnosed with stroke. Over half (57%, n = 2,415) of patients diagnosed with stroke experienced an acute ischemic stroke. Of patients with ischemic stroke, 26% (n = 628) were diagnosed with LVO. A CPSS score of 2 or higher demonstrated sensitivity = 69% and specificity = 78% for LVO. A RACE score of 4 or higher demonstrated sensitivity = 63%, specificity = 73%. A LAMS score of 3 or higher demonstrated sensitivity = 63%, specificity = 72% and a positive VAN score demonstrated sensitivity = 86%, specificity = 65%. Comparing the area under the ROC curve for each scale revealed no statistically significant differences in discriminative ability for LVO stroke.

CONCLUSIONS

In this large sample of real-world prehospital patient encounters, the CPSS demonstrated similar predictive performance characteristics compared to the RACE, LAMS, and VAN for detecting LVO stroke. Prior to implementing a specific screening tool, EMS agencies should evaluate ease of use and associated implementation costs. Scored 0-3, the simple, widely-used CPSS may serve as a favorable prehospital screening instrument for LVO detection with a cut-point of 2 or higher maximizing the tradeoff between sensitivity and specificity.

Cerebral Microbleeds in a Stroke Prevention Clinic

The objective of this study was to assess the effectiveness of a stroke clinic in stroke prevention and progression of cerebral microbleeds (CMB). We conducted a retrospective observational study of patients who visited a stroke clinic between January 2011 and March 2017. Susceptibility-weighted imaging (SWI) MRI studies were obtained at baseline and follow-up visits to identify new infarctions and CMB progression. Patients with CMB who also underwent brain computed tomography (CT) imaging were identified and their cerebral arterial calcification was quantified to evaluate the relationship between the extent of intracranial calcification and CMB burden. A total of 64 stroke patients (mean age 73.1 ± 11.0, 47% males) had CMB on baseline and follow-up MRI studies. During a mean follow-up period of 22.6 months, four strokes occurred (4/64, 6%; 3 ischemic, 1 hemorrhagic), producing mild neurological deficit. Progression of CMB was observed in 54% of patients with two MRIs and was significantly associated with length of follow-up. Subjects with intracranial calcification score > 300 cm³ had higher CMB count than those with scores <300 cm³ at both baseline (12.6 ± 11.7 vs. 4.9 ± 2.2, p = 0.02) and follow-up (14.1 ± 11.8 vs. 5.6 ± 2.4, p = 0.03) MRI evaluations. Patients with CMB had a relatively benign overall clinical course. The association between CMB burden and intracranial calcification warrants further study.

The association of gout with an increased risk of hypertension and diabetes mellitus among stroke survivors in New Zealand: A cross-sectional study using routinely collected electronic health data

Background

There is a paucity of data relating to the association of gout with the occurrence of hypertension and diabetes mellitus in patients with stroke. This study aimed to determine the association of gout with the risk of hypertension and diabetes mellitus in a cohort of stroke patients from Auckland, Aotearoa New Zealand.

Methods

A cross-sectional study was conducted among stroke survivors in South and East Auckland, New Zealand from the years 2010 to 2014. Electronic health record data were collected and analysed using Statistical Package for Social Science version 23. Multivariate logistic regression modelling adjusted for age, gender, and ethnicity was conducted to determine the association of gout with the risk of hypertension and diabetes mellitus in patients discharged with a diagnosis of stroke.

Results

The age-, gender-, and ethnicity-adjusted odds ratio for having hypertension and diabetes mellitus among stroke survivors with gout history were 3.25 (95% confidence interval 1.32–8.03) and 1.94 (95% confidence interval 1.12–3.36), respectively. Māori stroke survivors with gout history had the highest risk of having diabetes mellitus with age- and gender-adjusted odds ratio of 5.10 (95% confidence interval 1.90–18.93).

Conclusion

The findings from this study suggest gout may be independently associated with an increased risk of hypertension and diabetes mellitus in patients with stroke. Māori who are the indigenous population of New Zealand show a greater risk of diabetes mellitus associated with a gout diagnosis compared to other populations. This finding highlights the importance of the need for further research with Māori stroke survivors and other indigenous populations.

Sensitivity of Administrative Coding in Identifying Inpatient Acute Strokes Complicating Procedures or Other Diseases in UK Hospitals

Background

Administrative hospital diagnostic coding data are increasingly used in “big data” research and to assess complication rates after surgery or acute medical conditions. Acute stroke is a common complication of several procedures/conditions, such as carotid interventions, but data are lacking on the sensitivity of administrative coding in identifying acute stroke during inpatient stay.

Methods and Results

Using all acute strokes ascertained in a population‐based cohort (2002–2017) as the reference, we determined the sensitivity of hospital administrative diagnostic codes (International Classification of Diseases, Tenth Revision; ICD‐10) for identifying acute strokes that occurred during hospital admission for other reasons, stratified by coding strategies, study periods, and stroke severity (National Institutes of Health Stroke Score</≥5). Of 3011 acute strokes, 198 (6.6%) occurred during hospital admissions for procedures/other diseases, including 122 (61.6%) major strokes. Using stroke‐specific codes (ICD‐10=I60–I61 and I63–I64) in the primary diagnostic position, 66 of the 198 cases were correctly identified (sensitivity for any stroke, 33.3%; 95% CI, 27.1–40.2; minor stroke, 30.3%; 95% CI, 21.0–41.5; major stroke, 35.2%; 95% CI, 27.2–44.2), with no improvement of sensitivity over time (P_trend=0.54). Sensitivity was lower during admissions for surgery/procedures than for other acute medical admissions (n/% 17/23.3% versus 49/39.2%; P=0.02). Sensitivity improved to 60.6% (53.6–67.2) for all and 61.6% (50.0–72.1) for surgery/procedures if other diagnostic positions were used, and to 65.2% (58.2–71.5) and 68.5% (56.9–78.1) respectively if combined with use of all possible nonspecific stroke‐related codes (ie, adding ICD‐10=I62 and I65–I68).

Conclusions

Low sensitivity of administrative coding in identifying acute strokes that occurred during admission does not support its use alone for audit of complication rates of procedures or hospitalization for other reasons.

Predictors of Atrial Fibrillation in Patients With Cryptogenic Stroke

Background and Purpose

Many patients diagnosed with cryptogenic stroke or transient ischemic attack are subsequently found to have atrial fibrillation (AF) on outpatient cardiac telemetry monitoring. Identification of predictive factors for the detection of AF could assist with patient selection to increase the yield of telemetry and hasten initiation of appropriate secondary stroke prevention.

Methods

This was a retrospective cross-sectional study of patients diagnosed with cryptogenic stroke at a comprehensive stroke center and referred for at least 21 days of prolonged outpatient telemetry. Telemetry reports and data from the patient's stroke hospitalization, including imaging studies, electrocardiogram (EKG), echocardiogram, vital signs, and laboratory data, were reviewed.

Results

Ten percent of the 121 patients included in the study were diagnosed with AF based on outpatient telemetry. There was a strong association between presence of premature atrial contractions (PACs) on admission EKG and subsequent detection of AF (P = .004). Large left atrial diameter on echocardiogram was correlated with AF detection in males (P = .024). However, there was no association between AF and other echocardiographic measurements. Thyroid-stimulating hormone (TSH) levels were significantly higher in patients with cryptogenic stroke having AF (P = .008), with a TSH greater than 4.20 mIU/L predictive of detection of AF (P < .001).

Conclusions

Atrial fibrillation was found by outpatient monitoring in a notable percentage of patients with cryptogenic stroke. Predictors of occult AF in our study population included PACs and higher TSH levels. Although an association between low TSH and AF has been well established, our results suggest that high TSH may be a predictive factor as well.

High in-hospital blood pressure variability and severe disability or death in primary intracerebral hemorrhage patients

OBJECTIVE

To quantify in-hospital systolic blood pressure variability among patients with intracerebral hemorrhage, determine the association between high systolic blood pressure variability (HSBPV) and 90-day severe disability or death, and examine the association between pre-hospital factors and HSBPV.

METHODS

Adult, radiologically confirmed, intracerebral hemorrhage patients enrolled in a multi-site cohort were included. Using a semi-automated algorithm, systolic blood pressure values recorded from routine non-invasive systolic blood pressure monitoring in critical and acute care settings were extracted for the duration of hospitalization. Inter and intra-patient systolic blood pressure variability was quantified using generalized estimating equation methods. Modified Poisson and logistic regression models were fit to determine the association between HSBPV and 90-day severe disability or death and between pre-hospital characteristics and HSBPV, respectively.

RESULTS

A total of 566 patients managed at four certified stroke centers were included. Over 120,000 systolic blood pressure readings were analyzed, and a standard deviation (SD) of 13.0 was parameterized as a cut-off point to categorize HSBPV. Patients with HSBPV had a greater risk of 90-day severe disability or death (relative risk: 1.20, 95% confidence interval: 1.04-1.39), after controlling for age, pre-morbid functional status, and other disease severity measures. Greater likelihood of in-hospital HSBPV was independently observed in elderly, female patients, and in patients with high admission systolic blood pressure.

CONCLUSION

Quantification of HSBPV is feasible utilizing routinely collected systolic blood pressure readings, and a singular cut-off parameter for systolic blood pressure variability demonstrated association with 90-day severe disability or death. Elderly, female, and patients with high admission systolic blood pressure may be more likely to demonstrate HSBPV during hospitalization.

Breastfeeding History and Risk of Stroke Among Parous Postmenopausal Women in the Women's Health Initiative

Background Stroke is the third leading cause of death among US Hispanic and non-Hispanic black women aged 65 and older. One factor that may protect against stroke is breastfeeding. Few studies have assessed the association between breastfeeding and stroke and whether this association differs by race and ethnicity. Methods and Results Data were taken from the Women's Health Initiative Observational Study with follow-up through 2010; adjusted hazard ratios for stroke subsequent to childbirth were estimated with Cox regression models accounting for left and right censoring, overall and stratified by race/ethnicity. Of the 80 191 parous women in the Women's Health Initiative Observational Study, 2699 (3.4%) had experienced a stroke within a follow-up period of 12.6 years. The average age was 63.7 years at baseline. Fifty-eight percent (n=46 699) reported ever breastfeeding; 83% were non-Hispanic white, 8% were non-Hispanic black, 4% were Hispanic, and 5% were of other race/ethnicity. After adjustment for nonmodifiable potential confounders, compared with women who had never breastfed, women who reported ever breastfeeding had a 23% lower risk of stroke (adjusted hazard ratio=0.77; 95% confidence interval 0.70-0.83). This association was strongest for non-Hispanic black women (adjusted hazard ratio=0.52; 95% confidence interval 0.37-0.71). Further, breastfeeding for a relatively short duration (1-6 months) was associated with a 19% lower risk of stroke (adjusted hazard ratios=0.81; 95% confidence interval 0.74-0.89). This association appeared stronger with longer breastfeeding duration and among non-Hispanic white and non-Hispanic black women (test for trend P<0.01). Conclusions Study results show an association and dose-response relationship between breastfeeding and lower risk of stroke among postmenopausal women after adjustment for multiple stroke risk factors and lifestyle variables. Further investigation is warranted.

Effect of Change in Total Cholesterol Levels on Cardiovascular Disease Among Young Adults

Background

Although high serum cholesterol in young adults is known to be a predictor for cardiovascular events, there is not enough evidence for the association of cholesterol level change with cardiovascular disease (CVD). This study aimed to evaluate whether the change in cholesterol is associated with incidence of CVD among young adults.

Methods and Results

We examined 2 682 045 young adults (aged 20–39 years) who had undergone 2 consecutive national health check‐ups provided by Korean National Health Insurance Service between 2002 and 2005. Cholesterol levels were classified into low (<180 mg/dL), middle (180–240 mg/dL) and high (≥240 mg/dL). CVD events were defined as ≥2 days hospitalization attributable to CVD for 10 years follow‐up. Increased cholesterol levels were significantly associated with elevated ischemic heart disease risk (adjusted hazard ration [aHR]=1.21; 95% confidence interval [CI]=1.03–1.42 in low‐high group and aHR=1.21; 95% CI=1.15–1.27 in middle‐high group) and cerebrovascular disease (CEVD) risk (aHR=1.24; 95% CI=1.05–1.47 in low‐high group and aHR=1.09; 95% CI=1.02–1.16 in middle‐high group). Decreased cholesterol levels were associated with reduced ischemic heart disease risk (aHR=0.91; 95% CI=0.88–0.95 in middle‐low group, aHR=0.65; 95% CI=0.56–0.75 in high‐low group and aHR=0.68; 95% CI=0.65–0.73 in high‐middle group). Furthermore, lower cerebrovascular disease risk (aHR=0.76; 95% CI=0.62–0.92) was observed in the high‐low group compared with patients with sustained high cholesterol.

Conclusions

The findings of our study indicate that increased cholesterol levels were associated with high CVD risk in young adults. Furthermore, young adults with decreased cholesterol levels had reduced risk for CVD.

World's First 24/7 Mobile Stroke Unit: Initial 6-Month Experience at Mercy Health in Toledo, Ohio

Background and purpose

As the fourth mobile stroke unit (MSU) in the nation, and the first 24/7 unit worldwide, we review our initial experience with the Mercy Health MSU and institutional protocols implemented to facilitate rapid treatment of acute stroke patients and field triage for patients suffering other time-sensitive, acute neurologic emergencies in Lucas County, Ohio, and the greater Toledo metropolitan area.

Methods

Data was prospectively collected for all patients transported and treated by the MSU during the first 6 months of service. Data was abstracted from documentation of on-scene emergency medical services (EMS) personnel, critical care nurses, and onboard physicians, who participated through telemedicine.

Results

The MSU was dispatched 248 times and transported 105 patients after on-scene examination with imaging. Intravenous (IV) tissue plasminogen activator (tPA) was administered to 10 patients; 8 patients underwent successful endovascular therapy after a large vessel occlusion was identified using CT performed within the MSU without post treatment symptomatic hemorrhage. Moreover, 14 patients were treated with IV anti-epileptics for status epilepticus, and 19 patients received IV anti-hypertensive agents for malignant hypertension. MSU alarm to on-scene times and treatment times were 34.7 min (25–49) and 50.6 min (44.4–56.8), respectively.

Conclusion

The world’s first 24/7 MSU has been successfully implemented with IV-tPA administration rates and times comparable to other MSUs nation-wide, while demonstrating rapid triage and treatment in the field for neurologic emergencies, including status epilepticus. With the rising number of MSUs worldwide, further data will drive standardized protocols that can be adopted nationwide by EMS.

Relationship Between Glycated Hemoglobin and Stroke Risk: A Systematic Review and Meta-Analysis

BACKGROUND

Diabetes mellitus is a major risk factor for ischemic stroke. Rising hemoglobin A_1c (HbA_1c) levels are associated with microvascular diabetes mellitus complication development; however, this relationship has not been established for stroke risk, a macrovascular complication.

METHODS AND RESULTS

We conducted a systematic review and meta-analysis of observational cohort and nested case-control cohort studies assessing the association between rising HbA_1c levels and stroke risk in adults (≥18 years old) with and without type 1 or type 2 diabetes mellitus. Random-effects model meta-analyses were used to calculate pooled adjusted hazard ratios (HRs) and their precision. The systematic review yielded 36 articles, of which 29 articles (comprising n=532 779 participants) were included in our meta-analysis. Compared to non-diabetes mellitus range HbA_1c (<5.7%), diabetes mellitus range HbA_1c (≥6.5%) was associated with an increased risk of first-ever stroke with average HR (95% confidence interval) of 2.15 (1.76, 2.63), whereas pre-diabetes mellitus range HbA_1c (5.7-6.5%) was not (average HR [95% confidence interval], 1.19 [0.87, 1.62]). For every 1% HbA_1c increment (or equivalent), the average HR (95% confidence interval) for first-ever stroke was 1.12 (0.91, 1.39) in non-diabetes mellitus cohorts and 1.17 (1.09, 1.25) in diabetes mellitus cohorts. For every 1% HbA_1c increment, both non-diabetes mellitus and diabetes mellitus cohorts had a higher associated risk of first-ever ischemic stroke with average HR (95% confidence interval) of 1.49 (1.32, 1.69) and 1.24 (1.11, 1.39), respectively.

CONCLUSIONS

A rising HbA_1c level is associated with increased first-ever stroke risk in cohorts with a diabetes mellitus diagnosis and increased risk of first-ever ischemic stroke in non-diabetes mellitus cohorts. These findings suggest that more intensive HbA_1c glycemic control targets may be required for optimal ischemic stroke prevention.

New biomarker for acute ischaemic stroke: plasma glycogen phosphorylase isoenzyme BB

BACKGROUND

Glycogen phosphorylase is the key enzyme that breaks down glycogen to yield glucose-1-phosphate in order to restore depleted energy stores during cerebral ischaemia. We sought to determine whether plasma levels of glycogen phosphorylase BB (GPBB) isoform increased in patients with acute ischaemic stroke (AIS).

METHODS

We studied plasma GPBB levels within 12 hours and again at 48±24 hours of symptom onset in 172 patients with imaging-confirmed AIS and 133 stroke-free individuals. We determined the ability of plasma GPBB to discriminate between cases and controls and examined the predictive value of plasma GPBB for 90-day functional outcome, 90-day survival and acute lesion volumes on neuroimaging.

RESULTS

The mean (SD) GPBB levels were higher in cases (46.3±38.6 ng/mL at first measurement and 38.6±36.5 ng/mL at second measurement) than in controls (4.1±7.6 ng/mL, p<0.01 for both). The area under the receiver operating characteristic (ROC) curve for case-control discrimination based on first GPBB measurement was 0.96 (95% CI 0.93 to 0.98). The sensitivity and specificity based on optimal operating point on the ROC curve (7.0 ng/mL) were both 93%. GPBB levels increased in 90% of patients with punctate infarcts (<1.5 mL) and in all patients admitted within the first 4.5 hours of onset. There was no correlation between GPBB concentration and either clinical outcome or acute infarct volume.

CONCLUSION

GPBB demonstrates robust response to acute ischaemia and high sensitivity for small infarcts. If confirmed in more diverse populations that also include stroke mimics, GPBB could find utility as a stand-alone marker for acute brain ischaemia.

Dyslipidemia and Risk of Cardiovascular Events in Patients With Atrial Fibrillation Treated With Oral Anticoagulation Therapy: Insights From the ARISTOTLE (Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation) Trial

BACKGROUND

Dyslipidemia is a major risk factor for cardiovascular events. The prognostic importance of lipoproteins in patients with atrial fibrillation is not well understood. We aimed to explore the association between apolipoprotein A1 (ApoA1) and B (ApoB) and cardiovascular events in patients with atrial fibrillation receiving oral anticoagulation.

METHODS AND RESULTS

Using data from the ARISTOTLE (Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation) trial, ApoA1 and ApoB plasma levels were measured at baseline in 14 884 atrial fibrillation patients. Median length of follow-up was 1.9 years. Relationships between continuous levels of ApoA1 and ApoB and clinical outcomes were evaluated using Cox models adjusted for cardiovascular risk factors, medication including statins, and cardiovascular biomarkers. A composite ischemic outcome (ischemic stroke, systemic embolism, myocardial infarction, and cardiovascular death) was used as the primary end point. Median (25th, 75th) ApoA1 and ApoB levels were 1.10 (0.93, 1.30) and 0.70 g/L (0.55, 0.85), respectively. In adjusted analyses, higher levels of ApoA1 were independently associated with a lower risk of the composite ischemic outcome (hazard ratio, 0.81; P<0.0001). Similar results were observed for the individual components of the composite outcome. ApoB was not significantly associated with the composite ischemic outcome (P=0.8240). Neither apolipoprotein was significantly associated with major bleeding. There was no interaction between lipoproteins and randomized treatment for the primary outcome (both P values ≥0.2448).

CONCLUSIONS

In patients with atrial fibrillation on oral anticoagulation, higher levels of ApoA1 were independently associated with lower risk of ischemic cardiovascular outcomes. Investigating therapies targeting dyslipidemia may thus be useful to improve cardiovascular outcomes in patients with atrial fibrillation.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00412984.

Increased Levels of Lectin-Like Oxidized Low-Density Lipoprotein Receptor-1 in Ischemic Stroke and Transient Ischemic Attack

Background

Soluble lectin‐like oxidized low‐density lipoprotein receptor‐1 (sLOX‐1) has been shown to be increased in patients with acute ischemic stroke. Here, we evaluated plasma sLOX‐1 levels and vascular carotid plaque LOX‐1 (ie, OLR1) gene expression in patients with ischemic stroke and transient ischemic attack (TIA) with particular focus on their relation to time since symptom onset.

Methods and Results

Plasma sLOX‐1 (n=232) and carotid plaque OLR1 gene expression (n=146) were evaluated in patients who were referred to evaluation for carotid endarterectomy, as well as in healthy control plasma (n=81). Patients were categorized according to presence of acute ischemic stroke or transient ischemic attack (n=35) ≤7 days, >7 days ≤3 months (n=90), >3 months (n=40), or no reported symptoms before study inclusion (n=67). Our major findings were the following: (1) Patients with carotid atherosclerosis had increased plasma sLOX‐1 levels as compared with controls. (2) Plaque OLR1 mRNA levels were increased in carotid plaques (n=146) compared with nonatherosclerotic vessels (ie, common iliac arteries of organ donors, n=10). (3) There were no differences in sLOX plasma levels or OLR1 gene expression when analyzed according to the time since relevant cerebral ischemic symptoms. (4) Also patients with severe carotid atherosclerosis without any previous ischemic events had raised sLOX‐1 levels. (5) Immunostaining showed colocalization between LOX‐1 and macrophages within the carotid plaques. (6) Also patients with acute stroke (within 7 days) caused by atrial fibrillation (n=22) had comparable raised sLOX‐1 levels.

Conclusions

sLOX‐1 levels are elevated in patients with ischemic stroke and transient ischemic attack independent of cause and time since the ischemic event.

Galectin-3 and risk of ischaemic stroke: Reasons for Geographic and Racial Differences in Stroke cohort

BACKGROUND AND PURPOSE

Galectin-3 is a biomarker of atherosclerotic and cardiovascular disease, and may be a useful marker for ischaemic stroke risk.

METHODS

The Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort enrolled and examined 30 239 US participants between 2003 and 2007 (41% black, 59% white and 55% in the southeastern stroke belt). Baseline galectin-3 was measured in 526 subjects with incident ischaemic stroke over 5.4 years and in a cohort random sample (CRS) of 947 participants. Cox proportional hazards models were used to calculate hazard ratios (HRs) of ischaemic stroke by quartiles of galectin-3.

RESULTS

In the CRS, galectin-3 was significantly higher with older age, black race, female sex, body mass index, hypertension, diabetes mellitus and kidney disease, and also in those who developed incident stroke. Participants with galectin-3 levels in the fourth versus first quartile had a 2.3-fold increased stroke risk [95% confidence interval (CI) 1.6, 3.4] in an unadjusted model. An interaction with age was found (P = 0.06), and therefore age-stratified analyses were performed. Amongst those younger than age 64, baseline galectin-3 in the second-fourth quartiles was associated with increased stroke risk (HR 3.0, 95% CI 1.6, 5.5) compared to the first quartile in an age-, race- and sex-adjusted model. The HR was 2.0 (95% CI 1.0, 4.0) with multivariable adjustment. There was no association amongst older participants.

CONCLUSIONS

Galectin-3 was associated with incident ischaemic stroke in younger but not older individuals. Confirmation of this finding, and elucidation of its implications for stroke pathophysiology and prevention, is needed.

Association Between Troponin Levels and Embolic Stroke of Undetermined Source

Background

Our aim was to determine whether patients with embolic strokes of undetermined source (ESUS) have higher rates of elevated troponin than patients with noncardioembolic strokes.

Methods and Results

CAESAR (The Cornell Acute Stroke Academic Registry) prospectively enrolled all adults with acute stroke from 2011 to 2014. Two neurologists used standard definitions to retrospectively ascertain the etiology of stroke, with a third resolving disagreements. In this analysis we included patients with ESUS and, as controls, patients with small‐ and large‐artery strokes; only patients with a troponin measured within 24 hours of stroke onset were included. A troponin elevation was defined as a value exceeding our laboratory's upper limit (0.04 ng/mL) without a clinically recognized acute ST‐segment elevation myocardial infarction. Multiple logistic regression was used to evaluate the association between troponin elevation and ESUS after adjustment for demographics, stroke severity, insular infarction, and vascular risk factors. In a sensitivity analysis we excluded patients diagnosed with atrial fibrillation after discharge. Among 512 patients, 243 (47.5%) had ESUS, and 269 (52.5%) had small‐ or large‐artery stroke. In multivariable analysis an elevated troponin was independently associated with ESUS (odds ratio 3.3; 95% confidence interval 1.2, 8.8). This result was unchanged after excluding patients diagnosed with atrial fibrillation after discharge (odds ratio 3.4; 95% confidence interval 1.3, 9.1), and the association remained significant when troponin was considered a continuous variable (odds ratio for log[troponin], 1.4; 95% confidence interval 1.1, 1.7).

Conclusions

Elevations in cardiac troponin are more common in patients with ESUS than in those with noncardioembolic strokes.

Human Papillomavirus Status and the Risk of Cerebrovascular Events Following Radiation Therapy for Head and Neck Cancer

Background

Radiation therapy (RT) is a standard treatment for head and neck cancer; however, it is associated with inflammation, accelerated atherosclerosis, and cerebrovascular events (CVEs; stroke or transient ischemic attack). Human papillomavirus (HPV) is found in nearly half of head and neck cancers and is associated with inflammation and atherosclerosis. Whether HPV confers an increased risk of CVEs after RT is unknown.

Methods and Results

Using an institutional database, we identified all consecutive patients treated with RT from 2002 to 2012 for head and neck cancer who were tested for HPV. The outcome of interest was the composite of ischemic stroke and transient ischemic attack, and the association between HPV and CVEs was assessed using Cox proportional hazard models, competing risk analysis, and inverse probability weighting. Overall, 326 participants who underwent RT for head and neck cancer were tested for HPV (age 59±12 years, 75% were male, 9% had diabetes mellitus, 45% had hypertension, and 61% were smokers), of which 191 (59%) were tumor HPV positive. Traditional risk factors for CVEs were similar between HPV‐positive and ‐negative patients. Over a median follow‐up of 3.4 years, there were 18 ischemic strokes and 5 transient ischemic attacks (event rate of 1.8% per year). The annual event rate was higher in the HPV‐positive patients compared with the HPV‐negative patients (2.6% versus 0.9%, P=0.002). In a multivariable model, HPV‐positive status was associated with a >4 times increased risk of CVEs (hazard ratio: 4.4; 95% confidence interval, 1.5–13.2; P=0.008).

Conclusions

In this study, HPV‐positive status is associated with an increased risk of stroke or transient ischemic attack following RT for head and neck cancer.

Subclinical Cerebrovascular Disease Increases the Risk of Incident Stroke and Mortality: The Northern Manhattan Study

BACKGROUND

The effects of white matter hyperintensity volume and subclinical brain infarcts on the risk of incident stroke, its ischemic subtypes, and mortality require further study in diverse samples.

METHODS AND RESULTS

Stroke-free participants in the Northern Manhattan Study underwent magnetic resonance imaging (N=1287; mean age 71±9 years, 60% women, 15% non-Hispanic white, 17% non-Hispanic black, 68% Hispanic) and were followed for a median of 8 years (interquartile range: 6-9 years). Cox models estimated proportional hazards of incident stroke of all types, ischemic stroke (and its subtypes), and mortality and stratified by race/ethnicity. In total 72 participants (6%) had incident strokes and 244 died (19%). In fully adjusted models, those with larger white matter hyperintensity volume had greater risk of all stroke types (hazard ratio [HR]: 1.4; 95% CI, 1.1-1.9), ischemic stroke (HR: 1.3; 95% CI, 1.0-1.8), and cryptogenic stroke (HR: 2.2; 95% CI, 1.1-4.4). White and black but not Hispanic participants had increased stroke risk (P<0.05 for heterogeneity for all and ischemic stroke). Those with subclinical brain infarct had greater risk for all stroke types (HR: 1.9; 95% CI, 1.1-3.3), ischemic stroke (HR: 2.2; 95% CI, 1.3-3.8), lacunar (HR: 4.0; 95% CI, 1.3-12.3), and cryptogenic stroke (HR: 3.6; 95% CI, 1.0-12.7), without significant heterogeneity across race/ethnic groups. Greater white matter hyperintensity volume increased both vascular (HR: 1.3; 95% CI, 1.1-1.7) and nonvascular (HR: 1.2; 95% CI, 1.0-1.5) mortality among Hispanic and white but not black participants (P=0.040 for heterogeneity). Subclinical brain infarct was associated with increased vascular mortality among Hispanic participants only (HR: 2.9; 95% CI, 1.4-5.8).

CONCLUSIONS

In this urban US sample, subclinical cerebrovascular lesions increased the risk of clinical stroke and vascular mortality and varied by race/ethnicity and lesion type.

Time Course of Evolution of Disability and Cause-Specific Mortality After Ischemic Stroke: Implications for Trial Design

Background

Outcome in stroke trials is often based on a 3‐month modified Rankin scale (mRS). How 3‐month mRS relates to longer‐term outcomes will depend on late recovery, delayed stroke‐related deaths, recurrent strokes, and nonstroke deaths. We evaluated 3‐month mRS and death/disability at 1 and 5 years in a population‐based cohort study.

Methods and Results

In 3‐month survivors of ischemic stroke (Oxford Vascular Study; 2002‐2014), we related 3‐month mRS to disability (defined as mRS >2) at 1 and 5 years and/or death rates (age/sex adjusted). Accrual of disability and index‐stroke‐related and nonstroke deaths in each poststroke year was categorized according to 3‐month mRS. Among 1606 patients with acute ischemic stroke, 181 died within 3 months, but 126 index‐stroke‐related deaths and 320 other deaths occurred during the subsequent 4866 patient‐years of follow‐up up to 5 years. Although 69/126 (54.8%) post‐3‐month index‐stroke‐related deaths occurred after 1 year, mRS>2 at 1 year strongly predicted these deaths (adjusted hazard ratio=21.94, 95%CI 7.88‐61.09, P<0.0001). Consequently, a 3‐month mRS >2 was a strong independent predictor of death at both 1 year (adjusted hazard ratio=6.67, 95%CI 4.16‐10.69, P<0.0001) and 5 years (adjusted hazard ratio=2.93, 95%CI 2.38‐3.60, P<0.0001). Although mRS improved by ≥1 point from 3 months to 1 year in 317/1266 (25.0%) patients with 3‐month mRS ≥1, improvement in mRS after 1 year was limited (improvement by ≥1 point: 91/858 [10.6%]; improvement to mRS ≤2: 13/353 [3.7%]).

Conclusions

Our results reaffirm use of the 3‐month mRS outcome in stroke trials. Although later recovery does occur, extending follow‐up to 1 year would capture most long‐term stroke‐related disability. However, administrative mortality follow‐up beyond 1 year has the potential to demonstrate translation of early disability gains into additional reductions in long‐term mortality without much erosion by non‐stroke‐related deaths.

Age-Specific Vascular Risk Factor Profiles According to Stroke Subtype

BACKGROUND

Ischemic and hemorrhagic stroke are increasingly recognized as heterogeneous diseases with distinct subtypes and etiologies. Information on variation in distribution of vascular risk factors according to age in stroke subtypes is limited. We investigated the prevalence of vascular risk factors in stroke subtypes in relation to age.

METHODS AND RESULTS

We studied a prospective multicenter university hospital-based cohort of 4033 patients. For patients with ischemic stroke caused by large artery atherosclerosis, small vessel disease, or cardioembolism and for patients with spontaneous intracerebral hemorrhage or aneurysmal subarachnoid hemorrhage, we calculated prevalences of vascular risk factors in 4 age groups: <55, 55 to 65, 65 to 75, and ≥75 years, and mean differences with 95% CIs in relation to the reference age group. Patients aged <55 years were significantly more often of non-white origin (in particular in spontaneous intracerebral hemorrhage and aneurysmal subarachnoid hemorrhage patients) and most often smoked (most prominent for aneurysmal subarachnoid hemorrhage patients). Patients aged <55 years with ischemic stroke caused by large artery atherosclerosis or small vessel disease more often had hypertension, hyperlipidemia, and diabetes mellitus than patients with ischemic stroke of cardiac origin. Overall, the frequency of hypertension, hyperlipidemia, and diabetes mellitus increased with age among all stroke subtypes, whereas smoking decreased with age. Regardless of age, accumulation of potentially modifiable risk factors was most pronounced in patients with ischemic stroke caused by large artery atherosclerosis or small vessel disease.

CONCLUSIONS

The prevalence of common cardiovascular risk factors shows different age-specific patterns among various stroke subtypes. Recognition of these patterns may guide tailored stroke prevention efforts aimed at specific risk groups.

The efficacy of thrombolysis in lacunar stroke - evidence from the Austrian Stroke Unit Registry

BACKGROUND AND PURPOSE

Intravenous thrombolysis (ivT) with recombinant tissue plasminogen activator is established in acute ischaemic stroke. Little is known, however, about its efficacy in different stroke subtypes.

METHODS

A retrospective analysis of 128 733 patients from the Austrian Stroke Unit Registry was performed. Patients were classified as lacunar (LacS) or non-lacunar ischaemic stroke (nonLacS) by use of the clinical syndrome and technical findings. Outcome parameters were the short term improvement in the stroke unit [the difference of the National Institutes of Health Stroke Scale (NIHSS) score at admission and at discharge] and the modified Rankin Scale (mRS) score at 3 months. Patients were assigned to four groups according to thrombolysis and stroke subtype. To control for confounding, patients were matched for variables identified with impact outcome and for variables of general interest (NIHSS at admission, mRS before stroke and general risk factors).

RESULTS

There were four matched groups of 401 cases each. In LacS median short term improvement was 3 [interquartile range (IQR) 2-5] NIHSS points in the thrombolysed patients and 2 (IQR 1-4) in the non-thrombolysed patients (P < 0.001). In the nonLacS groups median short term improvement was 3 (IQR 1-5) in the thrombolysed and 2 (IQR 0-4) in the non-thrombolysed patients (P < 0.001). At 3-month follow-up, ivT was significantly associated with a better functional outcome in LacS (P < 0.001) and nonLacS patients (P < 0.001). Taking magnetic resonance imaging as a requirement for stroke subtyping led to similar results.

CONCLUSIONS

Patients with both lacunar and non-lacunar stroke benefitted from ivT. The degree of improvement was similar in both groups.

Sex Differences in the Association Between Insulin Resistance and Incident Coronary Heart Disease and Stroke Among Blacks Without Diabetes Mellitus: The Jackson Heart Study

Background

Studies exploring the association between insulin resistance (IR) and cardiovascular disease in blacks have not been conclusive, especially for coronary heart disease (CHD). The McAuley index and homeostasis model assessment of IR (HOMA‐IR) perform differently in predicting cardiovascular disease. We investigated this association in the Jackson Heart Study, a large longitudinal cohort of blacks.

Methods and Results

IR was estimated for 3565 participants without diabetes mellitus and cardiovascular disease at baseline using the McAuley index and HOMA‐IR, and their associations with incident CHD and stroke (composite outcome) were compared. A lower McAuley index and higher HOMA‐IR are indicative of IR. Cox regression analysis was used to estimate adjusted hazard ratios for incident CHD and/or stroke. There were 158 events (89 CHD‐only, 58 stroke‐only, and 11 CHD/stroke) over a median follow‐up of 8.4 years. After adjustment for demographic factors, the risk of the composite outcome decreased with each SD increase in the McAuley index (hazard ratio 0.80; 95% CI: 0.67–0.96), with no attenuation after further accounting for CHD and stroke risk factors. When considered individually, McAuley index and HOMA‐IR were associated with CHD (hazard ratio 0.71, 95% CI: 0.55–0.92 and hazard ratio 1.33, 95% CI: 1.03–1.72, respectively), but not stroke risk. The logHOMA‐IR and CHD association was present in men, but not in women (P_interaction=0.01).

Conclusions

Both HOMA‐IR and the McAuley index demonstrate strong associations with CHD but not stroke risk in blacks. The logHOMA‐IR and CHD association was present in men, but not in women.

Association of Family History With Cardiovascular Disease in Hypertensive Individuals in a Multiethnic Population

BACKGROUND

Hypertension alone is a poor predictor of the individual risk of cardiovascular disease. Hereditary factors of which hypertension is merely a marker may explain why some hypertensive individuals appear more susceptible to cardiovascular disease, and why some ethnicities have more often seemingly hypertension-related cardiovascular disease than others. We hypothesize that, in hypertensive individuals, a positive family history of cardiovascular disease identifies a high-risk subpopulation.

METHODS AND RESULTS

Healthy Life in Urban Settings (HELIUS) is a cohort study among participants of Dutch, South-Asian Surinamese, African Surinamese, Ghanaian, Turkish, and Moroccan origin aged 70 years and younger. In participants with hypertension (n=6467), we used logistic regression to assess the association of family history of cardiovascular disease with prevalent stroke and nonstroke cardiovascular disease, adjusting for sex, age, education, and smoking. To detect ethnic differences, we tested for interaction between family history and ethnicity and stratified the analysis by ethnicity. A positive family history was associated with a higher prevalence of nonstroke cardiovascular disease (odds ratio [OR], 2.05; 95% CI, 1.65-2.54) and stroke (OR, 1.62; 95% CI, 1.19-2.20). The strongest association of family history with nonstroke cardiovascular disease was found among the Dutch (OR, 2.47; 95% CI, 1.37-4.44) and with stroke among the African Surinamese (OR, 2.17; 95% CI, 1.32-3.57). The interaction between family history and African Surinamese origin for stroke was statistically significant.

CONCLUSIONS

In multiethnic populations of hypertensive patients, a positive family history of cardiovascular disease may be used clinically to identify individuals at high risk for nonstroke cardiovascular disease regardless of ethnic origin and African Surinamese individuals at high risk for stroke.

Neurological Injury in Intermediate-Risk Transcatheter Aortic Valve Implantation

BACKGROUND

The application of transcatheter aortic valve implantation (TAVI) to intermediate-risk patients is a controversial issue. Of concern, neurological injury in this group remains poorly defined. Among high-risk and inoperable patients, subclinical injury is reported on average in 75% undergoing the procedure. Although this attendant risk may be acceptable in higher-risk patients, it may not be so in those of lower risk.

METHODS AND RESULTS

Forty patients undergoing TAVI with the Edwards SAPIEN-XT™ prosthesis were prospectively studied. Patients were of intermediate surgical risk, with a mean±standard deviation Society of Thoracic Surgeons score of 5.1±2.5% and a EuroSCORE II of 4.8±2.4%; participant age was 82±7 years. Clinically apparent injury was assessed by serial National Institutes of Health Stroke Scale assessments, Montreal Cognitive Assessments (MoCA), and with the Confusion Assessment Method. These identified 1 (2.5%) minor stroke, 1 (2.5%) episode of postoperative delirium, and 2 patients (5%) with significant postoperative cognitive dysfunction. Subclinical neurological injury was assessed using brain magnetic resonance imaging, including diffusion-weighted imaging (DWI) sequences preprocedure and at 3±1 days postprocedure. This identified 68 new DWI lesions present in 60% of participants, with a median±interquartile range of 1±3 lesions/patient and volumes of infarction of 24±19 μL/lesion and 89±218 μL/patient. DWI lesions were associated with a statistically significant reduction in early cognition (mean ΔMoCA -3.5±1.7) without effect on cognition, quality of life, or functional capacity at 6 months.

CONCLUSIONS

Objectively measured subclinical neurological injuries remain a concern in intermediate-risk patients undergoing TAVI and are likely to manifest with early neurocognitive changes.

CLINICAL TRIAL REGISTRATION

URL: http://www.anzctr.org.au. Australian & New Zealand Clinical Trials Registry: ACTRN12613000083796.

Histological Findings and Predictors of Cerebral Debris From Transcatheter Aortic Valve Replacement: The ALSTER Experience

Background

Histopathological analyses of debris captured by a cerebral protection system during transcatheter aortic valve replacement have been reported, but the origin of the captured debris was not determined and risk factors were not defined.

Methods and Results

Embolic debris was analyzed from 322 filters used in a dual‐cerebral‐filter protection system implemented during transcatheter aortic valve replacement for 161 patients (mean age 81 years, 82 male [51%], logistic EuroSCORE 19% [interquartile range 12–31%]). The debris capture rate was high, with debris from 97% of all patients (156 of 161). No differences by filter location were found (brachiocephalic trunk 86% [139 of 161], left carotid artery 91% [147 of 161]; adjusted P=0.999). Five prevalent types of debris were identified: thrombus (91%), arterial wall tissue (68%), valve tissue (53%), calcification (46%), and foreign material (30%). Female sex (P=0.0287, odds ratio 1.364, 95% CI 1.032–1.812) and diabetes mellitus (P=0.0116, odds ratio 1.474, 95% CI 1.089–2.001) were significant risk factors for embolic debris. Additional analysis showed significantly more valve tissue in patients with predilation (P=0.0294). Stroke and transient ischemic attack rates were 0.6% each (1 of 161).

Conclusion

This study showed a high rate of embolic debris consisting of typical anatomic structures known to be altered in patients with aortic stenosis undergoing transcatheter aortic valve replacement. Female patients with diabetes mellitus have increased risk of embolic debris and should be protected by a cerebral protection system during transcatheter aortic valve replacement. Because valve tissue embolizes more often in patients with predilation, procedural planning should consider this finding. Both cerebral arteries (brachiocephalic trunk, left carotid artery) should be protected in the same way.

A novel application of teleneurology: robotic telepresence in supervision of neurology trainees

BACKGROUND

Telemedicine is used for specialist consultation, patient evaluation, and remote monitoring. We propose that telemedicine has a valuable role in medical education through facilitating faculty supervision of trainees.

MATERIALS AND METHODS

We surveyed resident physician trainees and faculty at a single institution who provided service for acute neurologic consultations over 29 months. The survey compared experiences using the supervisory methods of telephone, robotic telepresence (RTP), and in-person interaction. Participants answered 10 questions addressing their experience relevant to faculty-trainee interaction quality and clinical supervision, achieved with the three supervisory methods under study.

RESULTS

Surveys were received from 20 of 36 trainees (56%) and 8 of 10 faculty members (80%). More than 90% of trainees and faculty strongly agreed that in-person communication was satisfactory for patient data review, problem synthesis, and refinement of the trainees' impressions, with RTP ranking a close second. Moreover, 38% of faculty and 70% of trainees reported the telephone method as unsatisfactory for reacquisition of patient history, data synthesis, and direct observation of trainees' clinical skills. RTP provided more than 90% of trainees with sufficient staff support and facilitated trainee autonomy.

CONCLUSIONS

Overall, 85% of both trainees and faculty preferred in-person supervision most, with RTP ranked second and telephone being least favored. Although in-person faculty supervision of trainees' management of neurologic emergencies is always preferred, it is not always practical. This survey highlights the valuable role of RTP in graduate medical education and RTP as preferred over telephone as an adjunctive supervision tool in residency.

MKEY, a Peptide Inhibitor of CXCL4-CCL5 Heterodimer Formation, Protects Against Stroke in Mice

Background

MKEY, a synthetic cyclic peptide inhibitor of CXCL4–CCL5 heterodimer formation, has been shown to protect against atherosclerosis and aortic aneurysm formation by mediating inflammation, but whether it modulates neuroinflammation and brain injury has not been studied. We therefore studied the role of MKEY in stroke‐induced brain injury in mice.

Methods and Results

MKEY was injected into mice after stroke with 60 minutes of middle cerebral artery occlusion. Infarct volume and neurological deficit scores were measured. Protein levels of CCL5 and its receptor CCR5 were detected by Western blot and fluorescence‐activated cell sorting (FACS), respectively. Numbers of microglia‐derived macrophages (MiMΦs) and monocyte‐derived MΦs (MoMΦs) in the brain, and their subsets, based on the surface markers CD45, CD11b, CCR2, CX3CR1, and Ly6C, were analyzed by FACS. MΦs and neutrophil infiltration in the ischemic brain were stained with CD68 and myeloperoxidase (MPO), respectively, and assessed by immunofluorescent confocal microscopy. The results showed that expressions of CCL5 and its receptor CCR5, were increased in the ischemic brain after stroke. MKEY injection significantly reduced infarct sizes and improved neurological deficit scores measured 72 hours after stroke. In addition, MKEY injection inhibited the number of MoMΦs, but not MiMΦs, in the ischemic brain. Furthermore, MKEY inhibited protein expression levels of Ly6C,CCR2, and CX3CR1 on MoMΦs. Lastly, the confocal study also suggests that the number of CD68‐positive MΦs and MPO‐positive neutrophils was inhibited by MKEY injection.

Conclusions

MKEY injection protects against stroke‐induced brain injury, probably by inhibiting MoMΦ‐mediated neuroinflammation.

Intra-Arterial Therapy and Post-Treatment Infarct Volumes: Insights From the ESCAPE Randomized Controlled Trial

BACKGROUND AND PURPOSE

The goal of reperfusion therapy in acute ischemic stroke is to limit brain infarction. The objective of this study was to investigate whether the beneficial effect of endovascular treatment on functional outcome could be explained by a reduction in post-treatment infarct volume.

METHODS

The Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion With Emphasis on Minimizing CT to Recanalization Times (ESCAPE) trial was a multicenter randomized open-label trial with blinded outcome evaluation. Among 315 enrolled subjects (endovascular treatment n=165; control n=150), 314 subject's infarct volumes at 24 to 48 hours on magnetic resonance imaging (n=254) or computed tomography (n=60) were measured. Post-treatment infarct volumes were compared by treatment assignment and recanalization/reperfusion status. Appropriate statistical models were used to assess relationship between baseline clinical and imaging variables, post-treatment infarct volume, and functional status at 90 days (modified Rankin Scale).

RESULTS

Median post-treatment infarct volume in all subjects was 21 mL (interquartile range =65 mL), in the intervention arm, 15.5 mL (interquartile range =41.5 mL), and in the control arm, 33.5 mL (interquartile range =84 mL; P<0.01). Baseline National Institute of Health Stroke Scale (P<0.01), site of occlusion (P<0.01), baseline noncontrast computed tomographic scan Alberta Stroke Program Early CT score (ASPECTS) (P<0.01), and recanalization (P<0.01) were independently associated with post-treatment infarct volume, whereas age, sex, treatment type, intravenous alteplase, and time from onset to randomization were not (P>0.05). Post-treatment infarct volume (P<0.01) and delta National Institute of Health Stroke Scale (P<0.01) were independently associated with 90-day modified Rankin Scale, whereas laterality (left versus right) was not.

CONCLUSIONS

These results support the primary results of the ESCAPE trial and show that the biological underpinning of the success of endovascular therapy is a reduction in infarct volume.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT01778335.

Transcranial Doppler Sonography in Pediatric Neurocritical Care: A Review of Clinical Applications and Case Illustrations in the Pediatric Intensive Care Unit

Transcranial Doppler sonography is a noninvasive, real-time physiologic monitor that can detect altered cerebral hemodynamics during catastrophic brain injury. Recent data suggest that transcranial Doppler sonography may provide important information about cerebrovascular hemodynamics in children with traumatic brain injury, intracranial hypertension, vasospasm, stroke, cerebrovascular disorders, central nervous system infections, and brain death. Information derived from transcranial Doppler sonography in these disorders may elucidate underlying pathophysiologic characteristics, predict outcomes, monitor responses to treatment, and prompt a change in management. We review emerging applications for transcranial Doppler sonography in the pediatric intensive care unit with case illustrations from our own experience.