Historical Redlining, Social Determinants of Health, and Stroke Prevalence in Communities in New York City.

Importance: Historical redlining was a discriminatory housing policy that placed financial services beyond the reach of residents in inner-city communities. The extent of the impact of this discriminatory policy on contemporary health outcomes remains to be elucidated. Objective: To evaluate the associations among historical redlining, social determinants of health (SDOH), and contemporary community-level stroke prevalence in New York City. Design, Setting, and Participants: An ecological, retrospective, cross-sectional study was conducted using New York City data from January 1, 2014, to December 31, 2018. Data from the population-based sample were aggregated on the census tract level. Quantile regression analysis and a quantile regression forests machine learning model were used to determine the significance and overall weight of redlining in relation to other SDOH on stroke prevalence. Data were analyzed from November 5, 2021, to January 31, 2022. Exposures: Social determinants of health included race and ethnicity, median household income, poverty, low educational attainment, language barrier, uninsurance rate, social cohesion, and residence in an area with a shortage of health care professionals. Other covariates included median age and prevalence of diabetes, hypertension, smoking, and hyperlipidemia. Weighted scores for historical redlining (ie, the discriminatory housing policy in effect from 1934 to 1968) were computed using the mean proportion of original redlined territories overlapped on 2010 census tract boundaries in New York City. Main Outcomes and Measures: Stroke prevalence was collected from the Centers for Disease Control and Prevention 500 Cities Project for adults 18 years and older from 2014 to 2018. Results: A total of 2117 census tracts were included in the analysis. After adjusting for SDOH and other relevant covariates, the historical redlining score was independently associated with a higher community-level stroke prevalence (odds ratio [OR], 1.02 [95% CI, 1.02-1.05]; P < .001). Social determinants of health that were positively associated with stroke prevalence included educational attainment (OR, 1.01 [95% CI, 1.01-1.01]; P < .001), poverty (OR, 1.01 [95% CI, 1.01-1.01]; P < .001), language barrier (OR, 1.00 [95% CI, 1.00-1.00]; P < .001), and health care professionals shortage (OR, 1.02 [95% CI, 1.00-1.04]; P = .03). Conclusions and Relevance: This cross-sectional study found that historical redlining was associated with modern-day stroke prevalence in New York City independently of contemporary SDOH and community prevalence of some relevant cardiovascular risk factors.

Factors Associated with Anticoagulation Initiation for New Atrial Fibrillation in an Urban Emergency Department.

Objective: To explore factors associated with anticoagulation (AC) initiation after atrial fibrillation (AF) diagnosis. Design: Retrospective cohort study. Setting: Urban medical center. Patients: Adults with emergency department (ED) diagnosis of new onset AF from 1/1/2017-1/1/2020 discharged home. Methods: We compared patients initiated on AC, our primary outcome, to those not initiated on AC. Stroke, major bleeding, and AC initiation within 1 year of visit were secondary outcomes. We hypothesized that minority race and non-English language preference are associated with failure to initiate AC. Results: Of 111 patients with AF, 88 met inclusion criteria. Mean age was 65 (SD 15); 47 (53%) were women. 49 (56%) patients were initiated on AC. Age (61 vs 68 years; P=.02), non-English language (28% vs 10%; P=.03), leaving ED against medical advice (AMA) (36% vs 14%; P=.04), and CHA2DS2-VASc score of 1 (41% vs 6%; P<=.001) were associated with no AC initiation. There were no associations between patient-reported race/ethnicity and AC. Cardiology consultation (83.67% vs 30.78%; P<.0001) and higher median CHA2DS2-VASc score (3[2-4]) vs. 2[1-4]; P=.047) were associated with AC. Of 73 patients with follow-up data at 1 year, 2 (8%) not initiated on AC had strokes, 2 (4%) initiated on AC had major bleeds, and 15 (62.5%) not initiated on AC in the ED subsequently were initiated on AC. Conclusion: More than half of ED patients with new AF eligible for AC were initiated on it. Work to improve AC utilization among patients with new AF who left AMA from ED and those who prefer to communicate in a non-English language may be warranted.

Cross-Sectional Retrospective Study to Identify Clinical and Radiographic Features Associated With VZV Reactivation in Cryptogenic Stroke Patients With CSF Testing.

Background and Purpose: A large proportion of ischemic stroke patients lack a definitive stroke etiology despite extensive diagnostic testing. Varicella-Zoster Virus (VZV) can directly invade blood vessels causing vasculitis and may be associated with cryptogenic stroke (CS). Methods: We conducted a retrospective cross-sectional study of CS patients tested for VZV. The following were considered evidence of VZV reactivation (VZV+): positive CSF VZV PCR, anti-VZV IgM in CSF, or anti-VZV IgG CSF/serum ratio of 1:10 or higher. We describe the cohort, report VZV+ proportion with 95% confidence intervals (CI) determined with the Wald method, and compare patient groups using standard statistical tests. Results: A total of 72 CS patients met full study inclusion criteria. Most of the patients were <65 years old, had few traditional vascular risk factors, and had multifocal infarcts. Mean age was 49 years (SD ±13) and 47% were women. A total of 14 patients (19.4%; CI: 11.4-30.8%) had evidence of CNS VZV reactivation. There was no difference in evaluated demographic or radiographic features between those with versus without evidence of VZV reactivation. History of ischemic stroke in the past year (11/14 vs 25/43, P<.05) and hypertension (13/14 vs 35/58 and P<.05) were associated with VZV+. Conclusion: We found a high proportion of CNS VZV reactivation in a cross-sectional cohort of CS patients selected for CSF testing. Testing for VZV might be reasonable in CS patients who are young, have multifocal infarcts, or had an ischemic stroke within the past year, but additional research is needed.

Treating High-Risk TIA and Minor Stroke Patients With Dual Antiplatelet Therapy: A National Survey of Emergency Medicine Physicians.

BACKGROUND: Treatment with aspirin plus clopidogrel, dual antiplatelet therapy (DAPT), within 24 hours of high-risk transient ischemic attack (TIA) or minor stroke symptoms to eligible patients is recommended by national guidelines. Whether or not this treatment has been adopted by emergency medicine (EM) physicians is uncertain. METHODS: We conducted an online survey of EM physicians in the United States. The survey consisted of 13 multiple choice questions regarding physician characteristics, practice settings, and usual approach to TIA and minor stroke treatment. We report participant characteristics and use chi-squared tests to compare between groups. RESULTS: We included 162 participants in the final study analysis. 103 participants (64%) were in practice for >5 years and 96 (59%) were at nonacademic centers; all were EM board-certified or board-eligible. Only 9 (6%) participants reported that they would start DAPT for minor stroke and 8 (5%) reported that they would start DAPT after high-risk TIA. Aspirin alone was the selected treatment by 81 (50%) participants for minor stroke patients who presented within 24 hours of symptom onset and were not candidates for thrombolysis. For minor stroke, 69 (43%) participants indicated that they would defer medical management to consultants or another team. Similarly, 75 (46%) of participants chose aspirin alone to treat high-risk TIA; 74 (46%) reported they would defer medical management after TIA to consultants or another team. CONCLUSION: In a survey of EM physicians, we found that the reported rate of DAPT treatment for eligible patients with high-risk TIA and minor stroke was low.

Emergency medicine physicians' perspectives on diagnostic accuracy in neurology: a qualitative study.

OBJECTIVES: We sought to understand the knowledge, attitudes, and beliefs of emergency medicine (EM) physicians towards non-specific neurological conditions and the use of clinical decision support (CDS) to improve diagnostic accuracy. METHODS: We conducted semi-structured interviews of EM physicians at four emergency departments (EDs) affiliated with a single US healthcare system. Interviews were conducted until thematic saturation was achieved. Conventional content analysis was used to identify themes related to EM physicians' perspectives on acute diagnostic neurology; directed content analysis was used to explore views regarding CDS. Each interview transcript was independently coded by two researchers using an iteratively refined codebook with consensus-based resolution of coding differences. RESULTS: We identified two domains regarding diagnostic safety: (1) challenges unique to neurological complaints and (2) challenges in EM more broadly. Themes relevant to neurology included: (1) knowledge gaps and uncertainty, (2) skepticism about neurology, (3) comfort with basic as opposed to detailed neurological examination, and (4) comfort with non-neurological diseases. Themes relevant to diagnostic decision making in the ED included: (1) cognitive biases, (2) ED system/environmental issues, (3) patient barriers, (4) comfort with diagnostic uncertainty, and (5) concerns regarding diagnostic error identification and measurement. Most participating EM physicians were enthusiastic about the potential for well-designed CDS to improve diagnostic accuracy for non-specific neurological complaints. CONCLUSIONS: Physicians identified diagnostic challenges unique to neurological diseases as well as issues related more generally to diagnostic accuracy in EM. These physician-reported issues should be accounted for when designing interventions to improve ED diagnostic accuracy.

Under Treatment of High-Risk TIA Patients with Clopidogrel-Aspirin in the Emergency Setting.

BACKGROUND: Treating high-risk transient ischemic attack (TIA) with dual antiplatelet therapy (DAPT) reduces subsequent ischemic stroke risk yet current rates of clopidogrel-aspirin treatment are uncertain. MATERIALS AND METHODS: We conducted a retrospective cohort study of consecutive TIA patients who presented to any of the four emergency departments (ED) of a single urban health system from 1/1/2018-3/1/2020. Medical record review was used to describe the cohort and assess clopidogrel-aspirin treatment. Patient eligibility for clopidogrel-aspirin was determined using relevant criteria from the Platelet-Oriented Inhibition in New TIA and Minor Ischemic Stroke (POINT) Trial. Comparisons among eligible patients who received versus did not receive clopidogrel-aspirin were conducted using t-test, chi-squared, and Mann-Whitney as indicated. RESULTS: We identified 248 TIA patients of whom 95 met eligibility criteria for clopidogrel-aspirin treatment. Among these 95 patients, mean age was 69.5 (SD: 12), 68.4% were women, and median ABCD2 score was 5 (IQR: 4-6). A total of 26/95 (27.4%) eligible patients received clopidogrel-aspirin within 24 hours of symptom onset. Appropriate clopidogrel-aspirin use was associated with having a stroke code called upon ED arrival (88.5% vs. 34.8%; P<0.001), being evaluated by a vascular neurologist (88.5% vs. 21.1%; P<0.001), and not presenting to the community ED site wherein only a single patient received clopidogrel-aspirin. CONCLUSIONS: In a multisite, single health system study, nearly three-fourths of high-risk TIA patients eligible for clopidogrel-aspirin treatment did not receive it. Appropriate clopidogrel-aspirin use was highest among patients seen by vascular neurologists and lowest at the community ED, though under treatment was evident at all sites.

Biomarkers of Coagulation and Inflammation in COVID-19-Associated Ischemic Stroke.

[Figure: see text].

Cost-Effectiveness of Advanced Neuroimaging for Transient and Minor Neurological Events in the Emergency Department.

Background Accurate diagnosis of patients with transient or minor neurological events can be challenging. Recent studies suggest that advanced neuroimaging can improve diagnostic accuracy in low-risk patients with transient or minor neurological symptoms, but a cost-effective emergency department diagnostic evaluation strategy remains uncertain. Methods and Results We constructed a decision-analytic model to evaluate 2 diagnostic evaluation strategies for patients with low-risk transient or minor neurological symptoms: (1) obtain advanced neuroimaging (magnetic resonance imaging brain and magnetic resonance angiography head and neck) on every patient or (2) current emergency department standard-of-care clinical evaluation with basic neuroimaging. Main probability variables were: proportion of patients with true ischemic events, strategy specificity and sensitivity, and recurrent stroke rate. Direct healthcare costs were included. We calculated incremental cost-effectiveness ratios, conducted sensitivity analyses, and evaluated various diagnostic test parameters primarily using a 1-year time horizon. Cost-effectiveness standards would be met if the incremental cost-effectiveness ratio was less than willingness to pay. We defined willingness to pay as $100 000 US dollars per quality-adjusted life year. Our primary and sensitivity analyses found that the advanced neuroimaging strategy was more cost-effective than emergency department standard of care. The incremental effectiveness of the advanced neuroimaging strategy was slightly less than the standard-of-care strategy, but the standard-of-care strategy was more costly. Potentially superior diagnostic approaches to the modeled advanced neuroimaging strategy would have to be >92% specific, >70% sensitive, and cost less than or equal to standard-of-care strategy's cost. Conclusions Obtaining advanced neuroimaging on emergency department patient with low-risk transient or minor neurological symptoms was the more cost-effective strategy in our model.

The effect of race on composite thrombotic events in patients with COVID-19.

COVID-19 associated coagulopathy and mortality related to thrombotic complications have been suggested as biological mediators in racial disparities related to COVID-19. We studied the adjusted prevalence of acute ischemic stroke, pulmonary embolism, myocardial infarction, and deep venous thrombosis stratified by race in hospitalized patients in one New York City borough during the local COVID-19 surge. The multi-racial cohort included 4299 patients hospitalized with COVID-19, 9% of whom were white, 40% black, 41% Hispanic and 10% Asian or other. We found a 6.1% prevalence of composite thrombotic events. There were no significant race-specific differences in thrombotic events when adjusting for basic demographics, socioeconomic factors, medical comorbidities or biomarkers using a stepwise regression model. We therefore found no evidence that the racial disparities related to COVID-19, and specifically thrombotic complications, are caused by biological differences in race.

Neurologic Syndromes Predict Higher In-Hospital Mortality in COVID-19.

OBJECTIVE: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is protean in its manifestations, affecting nearly every organ system. However, nervous system involvement and its effect on disease outcome are poorly characterized. The objective of this study was to determine whether neurologic syndromes are associated with increased risk of inpatient mortality. METHODS: A total of 581 hospitalized patients with confirmed SARS-CoV-2 infection, neurologic involvement, and brain imaging were compared to hospitalized non-neurologic patients with coronavirus disease 2019 (COVID-19). Four patterns of neurologic manifestations were identified: acute stroke, new or recrudescent seizures, altered mentation with normal imaging, and neuro-COVID-19 complex. Factors present on admission were analyzed as potential predictors of in-hospital mortality, including sociodemographic variables, preexisting comorbidities, vital signs, laboratory values, and pattern of neurologic manifestations. Significant predictors were incorporated into a disease severity score. Patients with neurologic manifestations were matched with patients of the same age and disease severity to assess the risk of death. RESULTS: A total of 4,711 patients with confirmed SARS-CoV-2 infection were admitted to one medical system in New York City during a 6-week period. Of these, 581 (12%) had neurologic issues of sufficient concern to warrant neuroimaging. These patients were compared to 1,743 non-neurologic patients with COVID-19 matched for age and disease severity admitted during the same period. Patients with altered mentation (n = 258, p = 0.04, odds ratio [OR] 1.39, confidence interval [CI] 1.04-1.86) or radiologically confirmed stroke (n = 55, p = 0.001, OR 3.1, CI 1.65-5.92) had a higher risk of mortality than age- and severity-matched controls. CONCLUSIONS: The incidence of altered mentation or stroke on admission predicts a modest but significantly higher risk of in-hospital mortality independent of disease severity. While other biomarker factors also predict mortality, measures to identify and treat such patients may be important in reducing overall mortality of COVID-19.

Associating cryptogenic ischemic stroke in the young with cardiovascular risk factor phenotypes.

Acute Ischemic Stroke (AIS) in the young is increasing in prevalence and the largest subtype within this cohort is cryptogenic. To curb this trend, new ways of defining cryptogenic stroke and associated risk factors are needed. We aimed to gain insights into the presence or absence of cardiovascular risk factors in cases of cryptogenic stroke. We conducted a retrospective cohort study of patients aged 18-49 who presented to an urban tertiary care center with AIS. We manually collected predefined demographic, clinical, laboratory and radiological variables. Clinical risk phenotypes were determined using these variables through multivariate analysis of patients with the small and large vessel disease subtypes (vascular phenotype) and cardioembolic subtype (cardiac phenotype). The resultant phenotype models were applied to cases deemed cryptogenic. Within the 449 patients who met criteria, patients with small and large vessel disease (vascular phenotype) had higher rates of hypertension, intracranial atherosclerosis, and diabetes mellitus, and higher admission glucose, HbA1c, admission blood pressure, and cholesterol compared to the patients with cardioembolic AIS. The cardioembolic subgroup (cardiac phenotype) had significantly higher rates of congestive heart failure (CHF), rheumatic heart disease, atrial fibrillation, clotting disorders, left ventricular hypertrophy, larger left atrial sizes, lower ejection fractions, and higher B-type natriuretic peptide and troponin levels. Adjusted multivariate analysis produced six variables independently associated with the vascular phenotype (age, male sex, hemoglobin A1c, ejection fraction (EF), low-density lipoprotein (LDL) cholesterol, and family history of AIS) and five independently associated with the cardiac phenotype (age, female sex, decreased EF, CHF, and absence of intracranial atherosclerosis). Applying these models to cryptogenic stroke cases yielded that 51.5% fit the vascular phenotype and 3.1% fit the cardiac phenotype. In our cohort, half of young patients with cryptogenic stroke fit the risk factor phenotype of small and large vessel strokes.

Head Computed tomography during emergency department treat-and-release visit for headache is associated with increased risk of subsequent cerebrovascular disease hospitalization.

OBJECTIVES: The occurrence of head computed tomography (HCT) at emergency department (ED) visit for non-specific neurological symptoms has been associated with increased subsequent stroke risk and may be a marker of diagnostic error. We evaluate whether HCT occurrence among ED headache patients is associated with increased subsequent cerebrovascular disease risk. METHODS: We conducted a retrospective cohort study of consecutive adult patients with headache who were discharged home from the ED (ED treat-and-release visit) at one multicenter institution. Patients with headache were defined as those with primary ICD-9/10-CM discharge diagnoses codes for benign headache from 9/1/2013-9/1/2018. The primary outcome of cerebrovascular disease hospitalization was identified using ICD-9/10-CM codes and confirmed via chart review. We matched headache patients who had a HCT (exposed) to those who did not have a HCT (unexposed) in the ED in a one-to-one fashion using propensity score methods. RESULTS: Among the 28,121 adult patients with ED treat-and-release headache visit, 45.6% (n=12,811) underwent HCT. A total of 0.4% (n=111) had a cerebrovascular hospitalization within 365 days of index visit. Using propensity score matching, 80.4% (n=10,296) of exposed patients were matched to unexposed. Exposed patients had increased risk of cerebrovascular hospitalization at 365 days (RR: 1.65: 95% CI: 1.18-2.31) and 180 days (RR: 1.62; 95% CI: 1.06-2.49); risk of cerebrovascular hospitalization was not increased at 90 or 30 days. CONCLUSIONS: Having a HCT performed at ED treat-and-release headache visit is associated with increased risk of subsequent cerebrovascular disease. Future work to improve cerebrovascular disease prevention strategies in this subset of headache patients is warranted.

Utility of Apical Lung Assessment on Computed Tomography Angiography as a COVID-19 Screen in Acute Stroke.

BACKGROUND AND PURPOSE: Evaluation of the lung apices using computed tomography angiography of the head and neck during acute ischemic stroke (AIS) can provide the first objective opportunity to screen for coronavirus disease 2019 (COVID-19). METHODS: We performed an analysis assessing the utility of apical lung exam on computed tomography angiography for COVID-19-specific lung findings in 57 patients presenting with AIS. We measured the diagnostic accuracy of apical lung assessment alone and in combination with patient-reported symptoms and incorporate both to propose a COVID-19 era AIS algorithm. RESULTS: Apical lung assessment when used in isolation, yielded a sensitivity of 0.67, specificity of 0.93, positive predictive value of 0.19, negative predictive value of 0.99, and accuracy of 0.92 for the diagnosis of COVID-19, in patients presenting to the hospital for AIS. When combined with self-reported clinical symptoms of cough or shortness of breath, sensitivity of apical lung assessment improved to 0.83. CONCLUSIONS: Apical lung assessment on computed tomography angiography is an accurate screening tool for COVID-19 and can serve as part of a combined screening approach in AIS.

Predictors of mortality for patients with COVID-19 and large vessel occlusion.

BACKGROUND: This study evaluates the mortality risk of patients with emergent large vessel occlusion (ELVO) and COVID-19 during the pandemic. METHODS: We performed a retrospective cohort study of two cohorts of consecutive patients with ELVO admitted to a quaternary hospital from March 1 to April 17, 2020. We abstracted data from electronic health records on baseline, biomarker profiles, key time points, quality measures and radiographic data. RESULTS: Of 179 patients admitted with ischemic stroke, 36 had ELVO. Patients with COVID-19 and ELVO had a higher risk of mortality during the pandemic versus patients without COVID-19 (OR 16.63, p = 0.004). An age-based sub-analysis showed in-hospital mortality in 60% of COVID-19 positive patients between 61-70 years-old, 66.7% in between 51-60 years-old, 50% in between 41-50 years-old and 33.3% in between 31-40 years old. Patients that presented with pulmonary symptoms at time of stroke presentation had 71.4% mortality rate. 27.3% of COVID-19 patients presenting with ELVO had a good outcome at discharge (mRS 0-2). Patients with a history of cigarette smoking (p = 0.003), elevated d-dimer (p = 0.007), failure to recanalize (p = 0.007), and elevated ferritin levels (p = 0.006) had an increased risk of mortality. CONCLUSION: Patients with COVID-19 and ELVO had a significantly higher risk for mortality compared to COVID-19 negative patients with ELVO. A small percentage of COVID-19 ELVO patients had good outcomes. Age greater than 60 and pulmonary symptoms at presentation have higher risk for mortality. Other risk factors for mortality were a history of cigarette smoking, elevated, failure to recanalize, elevated d-dimer and ferritin levels.

The effect of COVID-19 on stroke hospitalizations in New York City.

BACKGROUND: Little is known about the effect of the Coronavirus disease 2019 pandemic on stroke care and the impact of the epidemic on acute stroke hospitalizations has not been described. METHODS: We analyze the stroke admission rate in three hospitals in New York City from January 1, 2020 through April 17, 2020, identifying all cases of acute ischemic stroke, intraparenchymal hemorrhage and subarachnoid hemorrhage. RESULTS: We confirmed 518 cases of out-of-hospital stroke. During the baseline period up to February 25, 2020, the daily stroke admission rate was stable, with the slope of the regression describing the number of admissions over time equal to -0.33 (se = 1.21), not significantly different from 0 (p = 0.79), with daily admissions averaging 41. During the pandemic period, the slope was -4.4 (se = 1.00); i.e., the number of stroke admissions decreased an average of 4.4 per week, (p = 0.005), with weekly admissions averaging 23, a reduction of 44% versus baseline. This general result was not different by patient age, sex, or race/ethnicity. CONCLUSIONS: The weekly stroke admission rate started declining two weeks prior to the local surge of coronavirus admissions. The consequences of lack of diagnosis and treatment of a large proportion of acute stroke patients are likely severe and lasting.

Folding a neuroscience center into streamlined COVID-19 response teams: Lessons in origami.

In response to the COVID-19 pandemic epicenter in Bronx, NY, the Montefiore Neuroscience Center required rapid and drastic changes when considering the delivery of neurologic care, health and safety of staff, and continued education and safety for house staff. Health care leaders rely on principles that can be in conflict during a disaster response such as this pandemic, with equal commitments to ensure the best care for those stricken with COVID-19, provide high-quality care and advocacy for patients and families coping with neurologic disease, and advocate for the health and safety of health care teams, particularly house staff and colleagues who are most vulnerable. In our attempt to balance these principles, over 3 weeks, we reformatted our inpatient neuroscience services by reducing from 4 wards to just 1, in the following weeks delivering care to over 600 hospitalized patients with neuro-COVID and over 1,742 total neuroscience hospital bed days. This description from members of our leadership team provides an on-the-ground account of our effort to respond nimbly to a complex and evolving surge of patients with COVID in a large urban hospital network. Our efforts were based on (1) strategies to mitigate exposure and transmission, (2) protection of the health and safety of staff, (3) alleviation of logistical delays and strains in the system, and (4) facilitating coordinated communication. Each center's experience will add to knowledge of best practices, and emerging research will help us gain insights into an evidence-based approach to neurologic care during and after the COVID-19 pandemic.

Bovine Arch and Stroke Laterality.

Background Left-hemispheric strokes are more frequent and often have a worse outcome than their right-hemispheric counterparts. This study aimed to evaluate whether cardioembolic stroke laterality is affected by anatomical characteristics of the aortic arch. We hypothesized that laterality varies between patients with bovine versus standard arch. Methods and Results We retrospectively identified 1598 acute cardioembolic strokes in patients with atrial fibrillation from our institutional stroke database (2009-2017). Inclusion criteria were acute anterior circulation ischemic infarct and availability of both arch and brain imaging (magnetic resonance imaging or computed tomography). Alternative causes of stroke and anomalous arch were excluded. Imaging was reviewed for stroke characterization and laterality and arch branching pattern. Bovine arch denotes a common origin of the brachiocephalic trunk and left common carotid artery. Strokes were classified as bilateral (left or right). Univariate analysis was performed using chi-square tests. The final cohort comprised 615 patients, mean age 77 years (SD 11.8 years) with 376 women (61%) and 33% white, 30% black, and the remainder mixed/Hispanic. Standard arch (n=424) stroke distribution was left 43.6% (185), right 45.1% (191), and bilateral 11.3% (48). Bovine arch (n=191) stroke distribution was left 51.3% (98), right 35.6% (68), and bilateral 13.1% (25). Bovine arches were associated with more left-sided strokes compared with standard arches (P=0.018). There was an association between black race and bovine arch (P=0.0001). Conclusions Bovine aortic arch configuration is associated with left hemispheric laterality of cardioembolic stroke. This study enriches the understanding that arch anatomy influences stroke laterality and highlights the need for further research into the causative hemodynamic factors.

Misdiagnosis of Cervicocephalic Artery Dissection in the Emergency Department.

Background and Purpose- Cervicocephalic artery dissection is an important cause of stroke. The clinical presentation of dissection can resemble that of benign neurological conditions leading to delayed or missed diagnosis. Methods- We performed a retrospective cohort study using statewide administrative claims data from all Emergency Department visits and admissions at nonfederal hospitals in Florida from 2005 to 2015 and New York from 2006 to 2015. Using validated International Classification of Diseases, Ninth Revision, CM codes, we identified adult patients hospitalized for cervicocephalic artery dissection. We defined probable misdiagnosis of dissection as having an Emergency Department treat-and-release visit for symptoms or signs of dissection, including headache, neck pain, and focal neurological deficits in the 14 days before dissection diagnosis. Multivariable logistic regression was used to compare adverse clinical outcomes in patients with and without probable misdiagnosis. Results- Among 7090 patients diagnosed with a dissection (mean age 52.7 years, 44.9% women), 218 (3.1% [95% CI, 2.7%-3.5%]) had a preceding probable Emergency Department misdiagnosis. After adjustment for demographics and vascular risk factors, there were no differences in rates of stroke (odds ratio, 0.82 [95% CI, 0.62-1.09]) or in-hospital death (odds ratio, 0.26 [95% CI, 0.07-1.08]) between dissection patients with and without a probable misdiagnosis at index hospitalization. Conclusions- We found that ≈1 in 30 dissection patients was probably misdiagnosed in the 2 weeks before their diagnosis.

"Basilar Web" Causing Basilar Branch Infarction.

We present a young patient with no vascular risk factors with a basilar branch infarction secondary to a shelf-like filling defect of the basilar artery. This defect was present and unchanged on repeat imaging and determined to be most consistent with a basilar web. Similar to carotid webs, a basilar web is believed to be an area of focal intimal fibroplasia that increases the risk of brainstem infarction. Focal fibroplasia of the posterior circulation should be considered when evaluating young adults with posterior circulation strokes of otherwise undetermined cause.