Journal of Stroke and Cerebrovascular Diseases

BackgroundLittle is known on the burden of ICU care for stroke patients. The aim of this study was to provide a description of management strategies, resource use, complications and their association with prognosis of stroke patients admitted to ICU. MethodsUsing a population-based stroke registry, we analyzed consecutive stroke patients admitted to 3 ICU with at least one organ failure between 2008 and 2017. The study period was divided into two periods corresponding to the arrival of mechanical reperfusion technique. Predictors of ICU mortality were separately assessed in two multivariable logistic regression models, a "clinical model" and an "intervention model". The same analysis was performed for predictors of functional status at hospital discharge. Results215 patients were included. Stroke etiology was ischemia in 109 patients (50.7%) and hemorrhage in 106 patients (49.3%). Median NIHSS score was 20.0 (9.0; 40.0). The most common reason for ICU admission was coma (41.2%) followed by acute circulatory failure (41%) and respiratory failure (27.4%). 112 patients (52%) died in the ICU and 20 patients (11.2%) had a good functional outcome (mRS[&le;]3) at hospital discharge. In the "clinical model," factors independently associated with ICU mortality were: age (OR = 1.03 [95%CI, 1.0 to 1.06]; p=0.04) and intracranial hypertension (OR = 6.89 [95%CI, 3.55 to 13.38]; p<0.0001). In the "intervention model," the need for invasive mechanical ventilation (OR = 7.39 [95%CI, 1.93 to 28.23]; p=0.004), the need for vasopressor therapy (OR = 3.36 [95%CI, 1.5 to 7.53]; p=0.003) and decision of withholding life support treatments (OR = 19.24 [95%CI, 7.6 to 48.65]; p<0.0001) were associated with bad outcome. ConclusionOur study showed the very poor prognosis of acute stroke patients admitted to ICU. These results also suggest that the clinical evolution of these patients during ICU hospitalization may provide important information for prognostication.

Background and PurposeVarious neurological complications have been reported in association with COVID-19. We report our experience of COVID-19 with stroke at a single center over a period of eight months spanning 1 March to 31 October 2020. MethodsWe recruited all patients admitted to Internal Medicine with an acute stroke, who also tested positive for COVID-19 on RTPCR. We included all stroke cases in our analysis for prediction of in-hospital mortality, and separately analyzed arterial infarcts for vascular territory of ischemic strokes. ResultsThere were 62 stroke cases among 3923 COVID-19 admissions (incidence 1.6%). Data was available for 58 patients {mean age 52.6 years; age range 17-91; F/M=20/38; 24% (14/58) aged [&le;]40; 51% (30/58) hypertensive; 36% (21/58) diabetic; 41% (24/58) with O2 saturation <95% at admission; 32/58 (55.17 %) in-hospital mortality}. Among 58 strokes, there were 44 arterial infarcts, seven bleeds, three arterial infarcts with associated cerebral venous sinus thrombosis, two combined infarct and bleed, and two of indeterminate type. Among the total 49 infarcts, Carotid territory was the commonest affected (36/49; 73.5%), followed by vertebrobasilar (7/49; 14.3%) and both (6/49; 12.2%). Concordant arterial block was seen in 61% (19 of 31 infarcts with angiography done). Early stroke (within 48 hours of respiratory symptoms) was seen in 82.7% (48/58) patients. Patients with poor saturation at admission were older (58 vs 49 years) and had more comorbidities and higher mortality (79% vs 38%). Mortality was similar in young strokes and older patients, although the latter required more intense respiratory support. Logistic regression analysis showed that low GCS and requirement for increasing intensity of respiratory support predicted in-hospital mortality. ConclusionsWe had a 1.6% incidence of COVID-19 related stroke of which the majority were carotid territory infarcts. In-hospital mortality was 55.17%, predicted by low GCS at admission.

BACKGROUNDDespite advancements in neurosurgery and intensive care that reduce overall mortality, poor-grade aneurysmal subarachnoid haemorrhage (aSAH) (World Federation of Neurosurgical Societies [WFNS] grades IV and V) remains a significant clinical challenge and is associated with persistently high mortality rates. The aim of this study was to assess the long-term outcomes of poor-grade aSAH and to identify factors influencing patient prognosis to guide clinical management. METHODSA multicentre, observational cohort study was conducted across 12 regional centres in northern China. The study included patients with poor-grade aSAH admitted from 2017 to 2020. The baseline data included demographics, clinical presentation, aneurysm characteristics, and treatment modalities. Outcome data, including survival status, mortality along with its associated causes and timing, and modified Rankin scale (mRS) scores, were collected prospectively at the last medical follow-up. Changes in case fatality over time were quantified with weighted linear regression. Survival analysis was performed to estimate survival and hazard ratios for death. Binary logistic regression was performed to estimate the odds ratio for dependency (mRS=3-5). RESULTSAmong the 1,589 enrolled patients, 1,339 were successfully followed, with an average follow-up of 26.37 months. Among them, 61.5% (824/1,339) were dependent or died. The overall mortality rate was 51% (684/1,339), and 21.3% (140/655) of the survivors were dependent. The risk factors for mortality included age [&ge;]65 years, previous history of stroke, and WFNS grade V. Additionally, conservative treatment and endovascular treatment were identified as risk factors and protective factors, respectively, compared with surgical treatment. WFNS grade V and middle cerebral artery aneurysms are independent risk factors for dependency. CONCLUSIONSAlthough there has been a downward trend in recent years, the long-term mortality rate for poor-grade aSAH has remained significantly high at 51%, with 21.3% of survivors being dependent. Active aneurysm treatment, to the extent possible, is crucial for improving the prognosis of these patients.

BackgroundTo validate JLK-CTL, an artificial intelligence (AI) software developed to predict large vessel occlusion (LVO) using non-contrast CT (NCCT) scans, and to investigate its clinical implications regarding both infarct volume and functional outcomes. MethodsBetween January-2021 and April-2023, a consecutive series of patients who concurrently underwent CT angiography and NCCT within 24 hours of last- known-well (LKW) were collected. LVO was confirmed through consensus among three experts reviewing CT angiography. Infarct volumes were quantified using diffusion-weighted imaging (DWI) conducted within seven days of the NCCT. The performance of the JLK-CTL was evaluated based on the area under the receiver operating characteristic curve (AUROC), as well as its sensitivity and specificity. The association of JLK-CTL LVO scores with infarct volumes and functional outcomes was assessed using Pearson correlation and logistic regression analyses, respectively. ResultsOf 1,391 screened patients, 774 (mean age 69.0 {+/-} 13.6 years, 57.6% men) were included. The median time from LKW to NCCT was 3.1 hours (IQR 1.5-7.4), with 24.2% (n=187) presenting LVO. The JLK-CTL demonstrated AUROC of 0.832 (95% CI 0.804-0.858), with a sensitivity of 0.711 (95% CI 0.641-0.775) and a specificity of 0.830 (95% CI 0.797-0.859) at the predefined threshold. Incorporating the National Institute of Health Stroke Scale into the model increased the AUROC to 0.872 (95% CI 0.846-0.894; p<0.001). The LVO scores showed a significant correlation with infarct volumes on follow-up DWI (r=0.53; p<0.001). When JLK-CTL LVO scores were categorized based on observed frequency of LVO, the highest JLK-CTL LVO scores (51-100) group showed an independent association with unfavorable functional outcomes (adjusted odds ratio 9.48; 95% CI 3.98-22.55). ConclusionThe performance of the AI software in predicting LVO was validated across multiple centers. This tool has the potential to assist physicians in optimizing stroke management workflows, especially in resource-limited settings.

BackgroundAlthough sepsis and delayed cerebral ischemia (DCI) are severe complications in patients with aneurysmal subarachnoid hemorrhage (aSAH) and share pathophysiological features, their interrelation and additive effect on functional outcome is uncertain. We investigated the association of sepsis with DCI and their cumulative effect on functional outcome in patients with aSAH using current sepsis-3 definition. MethodsPatients admitted to our hospital between 11/2014-11/2018 for aSAH were retrospectively analyzed. The main explanatory variable was sepsis, diagnosed using sepsis-3 criteria. Endpoints were DCI and functional outcome at hospital discharge (modified Rankin Scale (mRS) 0-3 vs. 4-6). Propensity score matching (PSM) and multivariable logistic regressions were performed. ResultsOf 238 patients with aSAH, 55 (23%) developed sepsis and 74 (31%) DCI. After PSM, aSAH patients with sepsis displayed significantly worse functional outcome (p<0.01) and longer ICU stay (p=0.046). Sepsis was independently associated with DCI (OR=2.46, 95%CI: 1.28-4.72, p<0.01). However, after exclusion of patients who developed sepsis before (OR=1.59, 95%CI: 0.78-3.24, p=0.21) or after DCI (OR=0.85, 95%CI: 0.37-1.95, p=0.70) this statistical association did not remain. Good functional outcome gradually decreased from 56% (76/135) in patients with neither sepsis nor DCI, to 43% (21/48) in those with no sepsis but DCI, to 34% (10/29) with sepsis but no DCI and to 8% (2/26) in patients with both sepsis and DCI. ConclusionsOur study demonstrates a strong association between sepsis, DCI and functional outcome in patients with aSAH and suggests a complex interplay resulting in a cumulative effect towards poor functional outcome, which warrants further studies.

Rebleeding is a major complication in patients admitted for aneurysmal subarachnoid hemorrhage. The optimal timing for aneurysm securing after the initial headache remains debated. The objective of this study was to evaluate the previously established predictive factors for rebleeding in a contemporary retrospective cohort (2020-2022, Rennes University Hospital). Among the 226 patients included in the analysis, 33 (15%) experienced rebleeding. The mean time-to-event (rebleeding or securing) was significantly shorter in patients without rebleeding compared with patients with rebleeding (36 {+/-} 3 vs. 63 {+/-} 9 hours, respectively, p<0.001). For each additional hour of delay since the first symptoms, the odds of rebleeding increased by 0.7% (OR = 1.007 [1.001-1.013], p=0.026). This association remains significant in multivariate analysis. Despite its limitations, this study highlights the importance of early management, taking into account the time elapsed since the initial headache.

BackgroundDifferentiating between intra-cerebral atherosclerotic disease (ICAD) and non-ICAD large vessel occlusion (LVO) is crucial for selecting the appropriate mechanical thrombectomy (MT) technique and device. We developed an algorithm to predict LVO etiology using clinical and radiographic features in the emergent setting. MethodsWe conducted a retrospective chart review of middle cerebral artery (MCA) occlusions treated with MT and confirmed as ICAD or non-ICAD. We recorded common risk factors and radiographic features from CT angiography to identify significant differences between groups. These factors were used in a multivariable logistic regression to create the algorithm. The ROME score was then tested against the ABC2D algorithm for predicting ICAD LVO in a prospective cohort. ResultsThe analysis included 33 ICAD and 327 non-ICAD LVO strokes. ICAD LVO patients were less likely to have atrial fibrillation (9.1% vs 53.8%; [points: 4]) or systolic heart failure with EF[&le;]35% (9.1% vs 27.8%; [points: 1) and more likely to present with progressive or fluctuating symptoms (21.2% vs 4.6%; [points: 1). ICAD patients had a higher incidence of multi-vessel atherosclerotic disease (84.8% vs 37%; [points: 1]), tapered appearance of occlusion (60.6% vs 0.9%; [points: 6]), and extra-cranial ICA atherosclerotic plaque with high-risk features (plaques with lengths [&ge;]1cm or thickness >3mm perpendicular to the long axis of the artery with associated ulceration or with soft plaque component (87.9% vs 37.6%; [points: 4]). AUC for the ROME score was 0.9666 with the highest sensitivity (97%) and specificity (88%) at a cut-off of 9. In the prospective cohort of 201 patients, the ROME score showed 81.3% sensitivity and 98.8% specificity, while the ABC2D score showed 90.6% sensitivity and 50.3% specificity. ConclusionOur scoring system effectively differentiates between ICAD and non-ICAD LVO, with greater specificity than the ABC2D score. Future steps will include validation in external databases and clinical trials.

BackgroundThe optimal noninvasive screening strategy for detecting patent foramen ovale (PFO) in patients with cryptogenic stroke (CS) remains uncertain. Although transthoracic echocardiography (TTE) and transcranial Doppler (TCD) are widely used, whether combining both modalities improves diagnostic performance has not been fully established. MethodsAmong 432 consecutive CS patients, 399 underwent collaborative screening with both TTE and TCD bubble tests performed by a multidisciplinary Heart-Brain Team, followed by transesophageal echocardiography (TEE) as the reference standard. Bubble tests were conducted at rest and during the Valsalva maneuver (VM). Diagnostic performance, concordance between modalities, and incremental value were evaluated using receiver operating characteristic analysis, Cohens kappa statistics, and sequential logistic regression models. ResultsTEE confirmed PFO in 156 patients (39.1%). Both TTE and TCD demonstrated significantly higher diagnostic accuracy during VM than at rest, with no significant difference in area under the curve between modalities under VM. Sequential logistic regression showed a significant incremental increase in predictive value when TCD during VM was added to TTE during VM ({chi}{superscript 2} increase from 271.4 to 297.2; p<0.0001). Although overall agreement between TTE and TCD during VM was substantial ({kappa}=0.63), 54 patients (14%) showed discordant results, among whom 15 (28%) had TEE-confirmed PFO. Applying an "OR" rule (positive if either test was positive) significantly improved sensitivity compared with either modality alone, at the expense of modestly reduced specificity. ConclusionsDual screening with TTE and TCD during VM within a Heart-Brain Team framework significantly enhances sensitivity for PFO detection and reduces missed diagnoses in patients with CS. An "OR" rule interpretation represents a practical and clinically effective screening strategy.

IntroductionAcute ischemic stroke is a major subtype of acute stroke. More than 65% of stroke-related deaths occur in developing countries. Various modifiable and non-modifiable risk factors are associated with the stroke. TOAST classification categorizes ischemic stroke into five etiologic subgroups. AimsTo identify subtypes of acute ischemic stroke and compare the influence of various risk factors on them. MethodologyA prospective observational study was conducted in a tertiary care teaching hospital. 200 consecutive patients diagnosed as having acute ischemic stroke were randomly enrolled. Patients were categorized into 3 groups-Group A: 18-39 years (17%); Group B: 40-60 years (20%) and Group C: >60 years (63%). Stroke subtypes were ascertained using TOAST classification. Data analysis was done. For categorical variables, data values were represented as numbers and percentages. A chi-square test was applied to find the level of significance. p value<0.05 was considered significant. ResultsThe study included 136 men and 64 women. Overall male dominance (Male: Female = 2.125:1), while in Group A, strong female dominance (Male: Female = 1:4.67) was observed. The commonest subtype was embolism (29.4%) in Group A, and small vessel disease in Group B, and C ((30% & 46.03% respectively). Hypertension was the commonest risk factor (62%). A higher incidence of hypertension was found in Group A (73.02%, p = 0.002), dyslipidemia in Group B (45%, p = 0.004), valvular heart disease (29.4%, p = 0.00001), and atrial fibrillation (29.4%, p = 0.005) in Group-C. Smoking and diabetes mellitus were strongly related to the male gender (p = 0.000001, p=0.002 respectively) and valvular heart disease to the female gender (p= 0.0002). ConclusionsAwareness of risk factors and lifestyle modifications may have a bearing on stroke prevention. Cardiovascular risk factors in young patients mandate the need for robust prevention and screening.

BackgroundUrinary tract infections (UTIs) are common among hospitalized stroke patients, leading to increased hospital stays and patient discomfort. While its known that post-stroke infections generally worsen outcomes, specific factors contributing to UTIs after stroke remain unclear. MethodsThis study aimed to investigate the incidence of post-stroke UTI (PSUTI) in patients admitted to the Hospitals from September 2020 to June 2021. The study included patients with a suspected diagnosis of stroke at the time of initial visit by a specialist. The final diagnosis was approved by an experienced neurologist and radiologist according to their brain CT scan. Data was collected from patients files, including demographics, comorbidities, drug history, smoking history, admission unit, clinical manifestations, systolic and diastolic blood pressure, type of stroke, etiology, laboratory findings, admission unit, in-hospital stay duration, therapies, use of NG tubes, urinary catheters, CV lines, brain drain, intratracheal tube, chest tube, dialysis catheter, and their durations. ResultsA study involving 612 patients found that PSUTI-positive patients had worse conditions at admission, with ischemic stroke being more common. They had longer stays in the ward or ICU, and were more likely to have a death outcome. The most common pathogen was Escherichia coli, followed by Staphylococcus epidermidis, Enterococcus spp, and Pseudomonas aeruginosa. In-hospital complications were more prevalent in PSUTI-positive patients, except for hydrocephalus and pulmonary embolism. Positive history of diabetes, falling symptoms, urinary catheter, and intubation were independent risk factors for post-stroke UTI. ConclusionThe study highlights the impact of urinary tract infections (UTIs) on stroke outcomes, revealing severe clinical profiles, comorbidities, longer hospital stays, and increased invasive interventions. Key risk factors like diabetes and urinary catheter use highlight the need for vigilant monitoring and tailored management strategies.

BackgroundCOVID-19 infection is associated with thrombotic events; however, this phenomenon is poorly understood. Few studies have reported the association between COVID-19 and stroke in the hospital setting. MethodsWe retrospectively reviewed and characterized all patients who presented to a single, quaternary medical center between March and December 2020 (N=603). COVID-19 positive patients who developed ischemic or hemorrhagic stroke were included in the analysis (N=66). This cohort was compared with patients who were COVID-19 negative at the time of stroke presentation in the same period (N=537). Statistical significance was evaluated using Pearsons Chi squared test with Yates continuity correction and linear model ANOVA. ResultsSixty-six patients had COVID-19 and Stroke. Of these patients, 22 (33.4%) patients initially presented with stroke and 44 (66.7%) initially presented with COVID-19. Patients who presented with COVID-19 and had a stroke during their hospitalization (COVID-first) had worse outcomes than patients presenting to the hospital with stroke whose COVID test became positive later in the hospitalization (stroke-first). Patients who presented with COVID-19 and had a stroke during their hospitalization had an increased rate of acute renal failure (48.9% vs 19.0%, p=0.021) and need for ventilation (60.0% vs 28.6%, p=0.017). Further, in the COVID-first cohort, the use of heparin prior to the stroke event was not associated with mortality or type of stroke (ischemic or hemorrhagic). ConclusionIn the early pandemic, patients with COVID-19 infection and stroke had a higher mortality rate compared to COVID-19 negative patients with stroke. Among patients with both COVID-19 and stroke, patients presenting with COVID-19 first had worse outcomes than patients presenting with stroke first. The use of heparin prior to the stroke event was not associated with mortality or type of stroke.

ObjectiveTo describe the ischemic stroke subtypes related to COVID-19 in a cohort of NYC hospitals and explore their etiopathogenesis. BackgroundExtra-pulmonary involvement of COVID-19 has been reported in the hepatic, renal and hematological systems. Most neurological manifestations are non-focal, but few have reported the characteristics of ischemic strokes or investigated its pathophysiology. MethodsData were collected prospectively from March 15 to April 15, 2020 from four centers in New York City to review possible ischemic stroke types seen in COVID-19 positive patients. Patient presentation, demographics, other related vascular risk factors, associated laboratory and coagulation markers, as well as imaging and outcomes for consecutive stroke patients positive for SARS-COV2 infection over the period studied were collected. ResultsIn our study, the age range of patients was 25-75 with no significant male preponderance. The median age of LVO patients was 48. Stroke was the presenting and hospitalizing event in 70%. One fifth of patients did not have common risk factors for ischemic stroke and none had atrial fibrillation, coronary or cerebrovascular disease, or were smokers. Half had a poor outcome with 40% ending in mortality (60% in LVO group) and one in a critical condition due ARDS. All had high neutrophil/lymphocyte ratio except one who demonstrated some neurological recovery. D-dimer levels showed mild to severe elevation when collected. None of the LVO cases had known cardiac risk factors but two out of five were found to have cardiac abnormalities during their hospitalization. All LVOs had hypercoagulable lab markers especially elevated D-dimer and/or fibrinogen. The LVO patients were younger and sicker with a median age of 46 and mean NIHSS of 24 as opposed to non-LVOs with a median age of 62 and mean NIHSS of 6 respectively. ConclusionCOVID-19 related ischemic events can be small vessel, branch emboli or large vessel occlusions. The latter is often associated with either a hypercoagulable state or cardio-embolism. Patient outcomes were worse when multi-organ or pulmonary system failure prevailed.

IntroductionA validated clinical decision tool predictive of favorable functional outcomes following endovascular thrombectomy (EVT) in acute ischemic stroke (AIS) remains elusive. We performed a retrospective case series of patients at our regional Comprehensive Stroke Center, over a 4-year period, who have undergone EVT to elucidate patient characteristics and factors associated with a favorable functional outcome after EVT. MethodsWe reviewed all cases of EVT at our institution from 2/2018 - 2/2022 in the extended time window from 6 - 24 hours. Demographic, clinical, imaging, and procedure co-variates were included. A favorable clinical outcome was defined as a modified Rankin scale or 0-2. We included patients with M1 or ICA occlusion treated with EVT within 6-24 hours after symptom onset. We used a univariate and multivariate logistic regression analysis to identify patient factors associated with a favorable clinical outcome at 90 days. ResultsOur analysis demonstrates that higher recanalization score based on the mTICI scale (2B-3) was a strong indicator of favorable outcome per both our multivariate and univariate analysis (OR 4.11; CI 1.10 - 15.31; p 0.035). Our data also showed signal that the younger age (p 0.013), lower baseline NIHSS (p 0.043), shorter hospital length of stay (LOS) (p 0.030), and absence of pre-existing hypertension (p 0.026) may also be a predictor of favorable outcome per our univariate analysis. ConclusionPatients without pre-existing hypertension had more favorable outcomes following EVT in the expanded time window. This is consistent with other multicenter data in the expanded time window that demonstrates greater odds of a poor outcome with elevated pre-, peri-, and post-endovascular treatment blood pressure. Our data also demonstrates mTICI score is a strong predictor of favorable outcome even when controlled for other variables. Other factors that may indicate a favorable outcome include younger age, lower baseline NIHSS, and shorter hospital LOS.

BackgroundImpairment in cerebral autoregulation has been proposed as a potentially targetable factor in patients with aneurysmal subarachnoid hemorrhage (aSAH), however there are different continuous measures that can be used to calculate the state of autoregulation. In addition, it has previously been proposed that there may be an association of impaired autoregulation with the occurrence of spreading depolarization (SD) events. MethodsSubjects with invasive multimodal monitoring and aSAH were enrolled in an observational study. Autoregulation indices were prospectively calculated from this database as a 10 second moving correlation coefficient between various cerebral blood flow (CBF) surrogates and mean arterial pressure (MAP). In subjects with subdural ECoG (electrocorticography) monitoring, SD was also scored. Associations between clinical outcomes using the mRS (modified Rankin Scale) and occurrence of either isolated or clustered SD was assessed. Results320 subjects were included, 47 of whom also had ECoG SD monitoring. As expected, baseline severity factors such as mFS and WFNS (World Federation of Neurosurgical Societies scale) were strongly associated with the clinical outcome. SD probability was related to blood pressure in a triphasic pattern with a linear increase in probability below MAP of [~]100mmHg. Autoregulation indices were available for intracranial pressure (ICP) measurements (PRx), PbtO2 from Licox (ORx), perfusion from the Bowman perfusion probe (CBFRx), and cerebral oxygen saturation measured by near infrared spectroscopy (OSRx). Only worse ORx and OSRx were associated with worse clinical outcomes. ORx and OSRx also were found to both increase in the hour prior to SD for both sporadic and clustered SD. ConclusionsImpairment in autoregulation in aSAH is associated with worse clinical outcomes and occurrence of SD when using ORx and OSRx. Impaired autoregulation precedes SD occurrence. Targeting the optimal MAP or cerebral perfusion pressure in patients with aSAH should use ORx and/or OSRx as the input function rather than intracranial pressure.

IntroductionCurrent reports indicate that the increased use of social distancing for preventive COID-19 distribution may have a negative effect on patients who suffering from acute medical conditions. AimWe examined the effect of social distancing on acute ischemic stroke (AIS) patients referral to the emergency department (ED) MethodA retrospective archive study was conducted between January 2017 and April 2020 in a comprehensive stroke center. We compare the number of neurologic consultations, time from symptoms onset to ED arrival, patients diagnosis with AIS, number of patients receiving treatment (tPA, endovascular thrombectomy (EVT) or combine) and in-hospital death. ResultsThe analysis included a total of 14,626 neurological consultations from the years 2017 to 2020. A significant decrease of 58.6% was noted during the months of January-April of the year 2020 compared to the parallel period of 2017. Percent of final AIS diagnosis for the year of 2020 represent 24.8% of suspected cases, with the highest diagnosis rate demarcated for the year of 2019 with 25.6% of confirmed patients. The most remarkable increase was noted in EVT performance through the examined years (2017, n=21; 2018, n=32; 2019, n=42; 2020, n=47). ConclusionCOVID-19 pandemic resulted in routing constraints on health care system resources that were dedicated for treating COVID-19 patients. The healthcare system must develop and offer complementary solutions that will enable access to health services even during these difficult times.

IntroductionThere are no recommendations for DSA in the ischemic stroke work-up according to current guidelines. We studied the rate of DSA in ischemic stroke, the recent time-trend (given the recent rapid increase in mechanical thrombectomy), hospital variation and associated factors. MethodsThis is a retrospective cross-sectional study among Medicare fee-for-service beneficiaries with ischemic stroke admitted between 2016 and 2020 in the United States. ICD-10 codes were used to determine ischemic stroke diagnosis and procedure codes for thrombectomy and DSA. Hospital trends and factors associated with DSA performance were analyzed in hospitals with DSA capacity. Results7.373 (0.7%) of the 1,085,644 ischemic stroke patients, had a DSA for diagnostic purposes. In the patients that were admitted to a hospital with DSA facility, the following factors showed the strongest association with DSA: younger age (aOR=0.81 [95% confidence interval (CI):0.81-0.83]), thrombectomy rate in that hospital (aOR=2549 [95%CI:610-10663]), transfer (aOR=1.41[95%CI:1.34-1.50]) and carotid disease (aOR=5.8 [95%CI:5.6-6.1]). There was large variation in the hospital DSA rate, varying from 0.07% to 11.1%. Of the variance of DSA rates, 15% was attributed to the residual effect hospital propensity to perform DSA. The top decile of hospitals with the highest DSA rate, performed DSAs in >2.3% of patients, compared to the 0.6% median. There was no change in DSA rates over time. ConclusionDSA is used infrequently in acute ischemic stroke patients and did not change between 2016 to 2020. Hospital variation in DSA use was however large, and not solely explained by patient and facility factors.

BackgroundRacial, gender, and socioeconomic disparities in stroke outcomes are well documented, but their impact on procedural success and clinical outcomes after endovascular treatment (EVT) for acute ischemic stroke remains unclear. MethodsWe retrospectively analyzed 584 acute ischemic stroke patients who underwent EVT (2016-2023), evaluating procedural reperfusion (TICI 2B-3), stroke severity (NIHSS/mRS) at admission and discharge, functional outcomes at discharge and 90 days (mRS), discharge disposition, and thrombolysis (tPA) administration. Multivariable logistic regression assessed independent predictors of outcomes. ResultsSuccessful reperfusion was achieved in 90.8%, with no significant differences by race, gender, or insurance status. Black patients and Medicare-insured individuals presented with significantly greater stroke severity (NIHSS [&ge;]9, p<0.05). Poor functional outcomes (mRS 3-6) at discharge and 90 days were significantly higher among Black patients, females, and Medicare-insured patients (p<0.05). Medicare and Medicaid patients were more frequently discharged to non-home settings. Insurance status was significantly associated with lower likelihood of tPA administration (p=0.006). Logistic regression showed that initial stroke severity strongly predicted outcomes, while procedural success was uniform across demographic groups. ConclusionsProcedural success of EVT was equitable; however, disparities persisted in stroke severity at admission and long-term outcomes. These findings highlight the need for systemic interventions addressing pre-hospital care, prevention, and equitable post-stroke rehabilitation access.

BackgroundStroke is a leading cause of public health burden in China, particularly among the elderly. This study aims to examine long-term trends in stroke incidence and the impact of population aging. MethodsUsing the Global Burden of Disease (GBD) Study 2021, we analyzed the incidence, mortality, and disability-adjusted life years (DALYs) for ischemic stroke (IS), cerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH) from 1990 to 2021. We applied the estimated annual percentage change (EAPC) and decomposition analysis to assess trends and the influence of population aging. FindingsFrom 1990 to 2021, the age-standardized incidence rate (ASIR) of IS rose from 110.05 to 135.79, with an EAPC of 0.94. The EAPCs for ICH and SAH were -2.24 and -3.70, respectively. Population aging significantly contributed to the stroke burden, with 800,000 IS-related deaths from 1980 to 2021. In 2021, the proportion of IS deaths due to aging was 279.4% for men and 204.8% for women. ConclusionsStroke incidence and mortality continue to rise, especially among the elderly. Aging exacerbates the stroke burden, highlighting the need for targeted policies to improve the quality of life for the aging population.

BackgroundLimited research exists regarding the impact of neuroimaging modality on endovascular thrombectomy (EVT) decisions for late window large vessel occlusion (LVO) stroke cases. PurposeThis study assesses whether perfusion CT imaging: 1) alters the proportion of recommendations for EVT, and 2) enhances the reliability of EVT decision-making compared to non-contrast CT and CT angiography. Materials and MethodsWe conducted an online survey using 30 patients drawn from an institutional database of 3144 acute stroke cranial CT scans. These cases were presented to 29 stroke or neurointerventional physicians from Canada across two sessions. Physicians evaluated each patient both with and without perfusion imaging and gave EVT recommendations. We used non-overlapping 95% confidence intervals and difference in agreement classification as criteria to suggest a difference between the Gwet AC1 statistics ({kappa}G). Our outcomes were: 1) the proportion of EVT recommendations, and 2) interrater and intrarater agreement, with or without perfusion imaging. ResultsIn the first round, 29 raters completed the assessment, with 28 finishing the second round. The percentage of EVT recommendations differed by 1.1% with or without perfusion imaging. However, individual decisions changed in 21.4% of cases, with 11.3% against EVT and 10.1% in favor. Interrater agreement ({kappa}G) among the 29 raters was similar between non-perfusion CT neuroimaging and perfusion CT neuroimaging ({kappa}G = 0.487; 95% CI 0.327, 0.647 and {kappa}G = 0.552; 95% CI 0.430, 0.675). The 95% CIs overlapped with moderate agreement in both. Intrarater agreement exhibited overlapping 95% CIs for all 28 raters. {kappa}G was either substantial or excellent (0.81-1) for 71.4% (20/28) of raters in both groups. ConclusionThe difference in EVT recommendations is minimal with either neuroimaing protocol. Regarding agreement we found that use of automated CT perfusion images does not significantly impact the reliability of EVT decisions for late window LVO patients.

Background and purposeGuidelines recommend patients with high-risk TIAs and minor stroke presenting within 1-3 days from onset be offered dual antiplatelet therapy (DAPT). There is little data on real-world adherence to these recommendations. We evaluated the appropriateness of DAPT use in TIA and stroke patients in a prospective Database. MethodsThe Qatar Stroke Database began enrollment of patients with TIAs and acute stroke in 2014 and currently has [~] 16,000 patients. For this study we evaluated the rates of guideline-adherent use of antiplatelet treatment at the time of discharge in patients with TIAs and stroke. TIAs were considered high-risk with ABCD2 score of 4 and minor stroke was defined as NIHSS 3. Patient demographics, clinical features, risk factors, previous medications, imaging and laboratory investigations, final diagnosis, discharge medications, and discharge and 90-day modified Rankin Scale (mRS) were analyzed. ResultsAfter excluding patients with ICH, mimics and rare secondary causes, 8082 patients available for final analysis (TIAs: 1357;stroke 6725). In high-risk TIAs, 282 of 666 (42.3%) patients were discharged on DAPT. In patients with minor stroke, 1207 of 3572 (33.8%) patients were discharged on DAPT. DAPT was inappropriately offered to 238 of 691 (34.4%) of low-risk TIAs and 809 of 3153 (25.7%) of non-minor stroke patients. ConclusionsThis large database of prospectively collected patients with TIAs and stroke shows that, unfortunately, despite several guidelines, a large majority of patients with TIAs and stroke are receiving inappropriate antiplatelet treatment at discharge from hospital. This requires urgent attention and further investigation.