Risk of Ischemic Stroke after an Inpatient Hospitalization for Transient Ischemic Attack in the United States.

INTRODUCTION: A diagnosis of transient ischemic attack (TIA) must be followed by prompt investigation and rapid initiation of measures to prevent stroke. Prior studies evaluating the risk of stroke after TIA were conducted in the emergency room or clinic settings. Experience of patients admitted to the hospital after a TIA is not well known. We sought to assess the early risk of ischemic stroke after inpatient hospitalization for TIA. METHODS: We used the 2010-2015 Nationwide Readmissions Database to identify all hospitalizations with the primary discharge diagnosis of TIA and investigated the incidence of ischemic stroke readmissions within 90 days of discharge from the index hospitalization. RESULTS: Of 639,569 index TIA admissions discharged alive (mean ± SD age 70.4 ± 14.4 years, 58.7% female), 9,131 (1.4%) were readmitted due to ischemic stroke within 90 days. Male sex, head/neck vessel atherosclerosis, hypertension, diabetes, atrial flutter/fibrillation, previous history of TIA/stroke, illicit drug use, and higher Charlson Comorbidity Index score were independently associated with readmissions due to ischemic stroke. Ischemic stroke readmissions were associated with excess mortality, discharge disposition other than to home, and elevated cost. CONCLUSIONS: Patients hospitalized for TIA have a lower risk of ischemic stroke compared to that reported in the studies based on the emergency room and/or outpatient clinic evaluation. Among these patients, those with cardiovascular comorbidities remain at a higher risk of readmission due to ischemic stroke despite undergoing an inpatient evaluation and should therefore be the target for future preventive strategies.

The Intracerebral Hemorrhage Score Overestimates Mortality in Young Adults.

OBJECTIVE: To determine whether the intracerebral hemorrhage (ICH) score is accurate in predicting 30-day mortality in young adults, we calculated the ICH score for 156 young adults (aged 18-45) with primary spontaneous ICH and compared predicted to observed 30-day mortality rates. METHODS: We retrospectively reviewed all patients aged 18-45 consecutively presenting to the University of Iowa from 2009 to 2019 with ICH. We calculated the ICH score and recorded its individual subcomponents for each patient. Poisson regression was used to test the association of ICH score components with 30-day mortality. RESULTS: We identified 156 patients who met the inclusion criteria; mean± standard deviation (SD) age was 35±8 years. The 30-day mortality rate was 15% (n=24). The ICH score was predictive of 30-day mortality for each unit increase (p= 0.04 for trend), but the observed mortality rates for each ICH score varied considerably from the original ICH score predictions. Most notably, the 30-day mortality rates for ICH scores of 1, 2, and 3 are predicted to be 13%, 26%, and 72% respectively, but were observed in our population to be 0%, 3%, and 41%. An ICH volume of >30cc [relative risk (RR) 28, 95% confidence intervals (CI) 3-315, p=0.01] and a GCS score of <5 (RR 13, 95% CI 0.1-1176, p=0.01) were independently associated with 30-day mortality. CONCLUSIONS: The ICH score tends to overestimate mortality in young adults. ICH volume and GCS score are the most relevant items in predicting mortality at 30 days in young adults.

Detection and Quantification of Symptomatic Atherosclerotic Plaques With High-Resolution Imaging in Cryptogenic Stroke.

BACKGROUND AND PURPOSE: High-resolution vessel wall imaging (HR-VWI) is a powerful tool in diagnosing intracranial vasculopathies not detected on routine imaging. We hypothesized that 7T HR-VWI may detect the presence of atherosclerotic plaques in patients with intracranial atherosclerosis disease initially misdiagnosed as cryptogenic strokes. METHODS: Patients diagnosed as cryptogenic stroke but suspected of having an intracranial arteriopathy by routine imaging were prospectively imaged with HR-VWI. If intracranial atherosclerotic plaques were identified, they were classified as culprit or nonculprit based on the likelihood of causing the index stroke. Plaque characteristics, such as contrast enhancement, degree of stenosis, and morphology, were analyzed. Contrast enhancement was determined objectively after normalization with the pituitary stalk. A cutoff value for plaque-to-pituitary stalk contrast enhancement ratio (CR) was determined for optimal prediction of the presence of a culprit plaque. A revised stroke cause was adjudicated based on clinical and HR-VWI findings. RESULTS: A total of 344 cryptogenic strokes were analyzed, and 38 eligible patients were imaged with 7T HR-VWI. Intracranial atherosclerosis disease was adjudicated as the final stroke cause in 25 patients. A total of 153 intracranial plaques in 374 arterial segments were identified. Culprit plaques (n=36) had higher CR and had concentric morphology when compared with nonculprit plaques (P≤0.001). CR ≥53 had 78% sensitivity for detecting culprit plaques and a 90% negative predictive value. CR ≥53 (P=0.008), stenosis ≥50% (P<0.001), and concentric morphology (P=0.030) were independent predictors of culprit plaques. CONCLUSIONS: 7T HR-VWI allows identification of underlying intracranial atherosclerosis disease in a subset of stroke patients with suspected underlying vasculopathy but otherwise classified as cryptogenic. Plaque analysis in this population demonstrated that culprit plaques had more contrast enhancement (CR ≥53), caused a higher degree of stenosis, and had a concentric morphology.

National Institutes of Health StrokeNet Training Core.

Background and Purpose- The National Institutes of Health (NIH) StrokeNet provides a nationwide infrastructure to advance stroke research. Capitalizing on this unique opportunity, the NIH StrokeNet Training Core (NSTC) was established with the overarching goal of enhancing the professional development of a diverse spectrum of professionals who are embedded in the stroke clinical trials network of the NIH StrokeNet. Methods- This special report provides a descriptive account of the rationale, organization, and activities of the NSTC since its inception in 2013. Current processes and their evolution over time for facilitating training of NIH StrokeNet trainees have been highlighted. Data collected for monitoring training are summarized. Outcomes data (publications and grants) collected by NSTC was supplemented by publicly available resources. Results- The NSTC comprises of cross-network faculty, trainees, and education coordinators. It helps in the development and monitoring of training programs and organizes educational and career development activities. Trainees are provided directed guidance towards their mandated research projects, including opportunities to present at the International Stroke Conference. The committee has focused on developing sustainable models of peer-to-peer interaction and cross-institutional mentorships. A total of 124 professionals (43.7% female, 10.5% underrepresented minorities) have completed training between 2013 and 2018, of whom 55% were clinical vascular neurologists. Of the total, 85% transitioned to a formal academic position and 95% were involved in stroke research post-training. Altogether, 1659 indexed publications have been authored or co-authored by NIH StrokeNet Trainees, of which 58% were published during or after their training years. Based on data from 109 trainees, 33% had submitted 72 grant proposals as principal or co-principal investigators of which 22.2% proposals have been funded. Conclusions- NSTC has provided a foundation to foster nationwide training in stroke research. Our data demonstrate strong contribution of trainees towards academic scholarship. Continued innovation in educational methodologies is required to adapt to unique training opportunities such as the NIH StrokeNet.

Differential Risk Factors and Outcomes of Ischemic Stroke due to Cervical Artery Dissection in Young Adults.

INTRODUCTION: Cervical artery dissection (CeAD) is a major cause of ischemic stroke in young adults. Our understanding of the specific risk factors and clinical course of CeAD is still evolving. In this study, we evaluated the differential risk factors and outcomes of CeAD-related strokes among young adults. METHODS: The study population consisted of young patients 15-45 years of age consecutively admitted with acute ischemic stroke to our comprehensive stroke center between January 1, 2010, and November 30, 2016. Diagnosis of CeAD was based on clinical and radiological findings. Univariate and multivariable logistic regression analyses were used to assess the risk factors and clinical outcomes associated with CeAD-related strokes. RESULTS: Of the total 333 patients with acute ischemic stroke included in the study (mean ± SD age: 36.4 ± 7.1 years; women 50.8%), CeAD was identified in 79 (23.7%) patients. As compared to stroke due to other etiologies, patients with CeAD were younger in age, more likely to have history of migraine and recent neck manipulation and were less likely to have hypertension, diabetes, and previous history of stroke. Clinical outcomes of CeAD were comparable to strokes due to other etiologies. Within the CeAD group, higher initial stroke severity and history of tobacco use were associated with higher modified Rankin Scale score at follow-up. CONCLUSIONS: While history of migraine and neck manipulation are significantly associated with CeAD, most of the traditional vascular risk factors for stroke are less prevalent in this group when compared to strokes due to other etiologies. For CeAD-related strokes, higher initial stroke severity and history of tobacco use may be associated with higher stroke-related disability, but overall, patients with CeAD have similar outcomes as compared to strokes due to other etiologies.

Secular Trends for Etiologies of Acute Ischemic Stroke in Young Adults.

BACKGROUND: Ischemic stroke is not rare among young adults. Understanding secular trends in the mechanism of ischemic stroke in young adults may help guide evaluation and secondary prevention. This study compares the mechanism of ischemic stroke and diagnostic studies in two groups of young adults treated at the University of Iowa 20 years apart. METHODS: We retrospectively reviewed all patients aged 15-45 who presented to the University of Iowa Hospitals between 1/2010-11/2016 with ischemic stroke confirmed by imaging. Diagnostic studies and stroke etiologies for each patient using the TOAST criteria were reviewed and compared to a historic sample of young patients of the same age who presented to our center in 1977-1993. RESULTS: We identified 322 young adults, 165 (51.2%) were women. The mean age was 36.3 ± 7.2 years. Vessel imaging was performed in 317 (95.2%) cases vs. 68.9% in the historic sample. Of these, 259 (80.4%) had magnetic resonance angiography (MRA), while diagnostic angiogram was the sole modality used for vessel imaging in the historic sample. Transthoracic echocardiography (TTE) was performed in 101 (31.4%) and transesophageal echocardiography (TEE) was performed in 169 (52.5%) cases compared to 67.1% who underwent TTE in the historic sample. In comparison with the historic sample, there was a significant decline in strokes due to small vessel disease [odds ratio (OR) 0.49, 95% confidence intervals (CI) 0.25-0.97]. The most common etiology of stroke in our sample was cervical artery dissection in 79 (24.5%) patients, whereas this was found in only 6.0% of patients in the historic sample [OR 5.0 and CI (2.99-8.44). CONCLUSIONS: Using the TOAST classification, cryptogenic stroke remained the most common subtype in young adults. While the most common cause for ischemic stroke was cervical artery dissection. DISCLOSURES: Enrique Leira receive salary support from the National Institute of Health.

Management of Ischemic Stroke Following Left Ventricular Assist Device.

BACKGROUND: Acute ischemic stroke is a common complication and an important source of morbidity and mortality in patients with left ventricular assist devices. There are no standardized protocols to guide management of ischemic stroke among patients with left ventricular assist device. We evaluated our experience treating patients who had an acute ischemic stroke following left ventricular assist device placement. METHODS: We retrospectively reviewed all patients who underwent left ventricular assist device placement from 2010-2019 and identified patients who had acute ischemic stroke following left ventricular assist device placement. RESULTS: Of 216 patients having left ventricular assist device placement (mean±SD age 52.9±16.2 years, women 26.9%), 19 (8.8%) had acute ischemic stroke (mean±SD age 55.8±12.0 years, women 36.8%). Median (interquartile range) time to ischemic stroke following left ventricular assist device placement was 96 (29-461) days. At the time of the ischemic stroke, 16/19 (84.2%) patients were taking both antiplatelet and anticoagulation therapy, 1/19 (5.3%) patient was receiving only anticoagulants, 1/19 (5.3%) patient was taking aspirin and dipyridamole, and 1/19 (5.3%) patient was not taking antithrombic agents. INR was subtherapeutic (INR<2.0) in 7/17 (41.2%) patients. No patient was eligible to receive thrombolytic therapy, while 5/19 (26.3%) underwent mechanical thrombectomy. Anticoagulation was continued in the acute stroke phase in 11/19 (57.9%) patients and temporarily held in 8/19 (42.1%) patients. Hemorrhagic transformation of the ischemic stroke occurred in 6/19 (31.6%) patients. Anticoagulation therapy was continued following ischemic stroke in 4/6 (66.7%) patients with hemorrhagic transformation. CONCLUSIONS: While thrombolytic therapy is frequently contraindicated in the management of acute ischemic stroke following left ventricular assist device, mechanical thrombectomy remains a valid option in eligible patients. Anticoagulation is often continued through the acute phase of ischemic stroke secondary to concerns for LVAD thrombosis. The risks and benefits of continuing anticoagulation must be weighed carefully, especially in patients with large infarct volume, as hemorrhagic transformation remains a common complication.

Pioglitazone after Ischemic Stroke or Transient Ischemic Attack.

BACKGROUND: Patients with ischemic stroke or transient ischemic attack (TIA) are at increased risk for future cardiovascular events despite current preventive therapies. The identification of insulin resistance as a risk factor for stroke and myocardial infarction raised the possibility that pioglitazone, which improves insulin sensitivity, might benefit patients with cerebrovascular disease. METHODS: In this multicenter, double-blind trial, we randomly assigned 3876 patients who had had a recent ischemic stroke or TIA to receive either pioglitazone (target dose, 45 mg daily) or placebo. Eligible patients did not have diabetes but were found to have insulin resistance on the basis of a score of more than 3.0 on the homeostasis model assessment of insulin resistance (HOMA-IR) index. The primary outcome was fatal or nonfatal stroke or myocardial infarction. RESULTS: By 4.8 years, a primary outcome had occurred in 175 of 1939 patients (9.0%) in the pioglitazone group and in 228 of 1937 (11.8%) in the placebo group (hazard ratio in the pioglitazone group, 0.76; 95% confidence interval [CI], 0.62 to 0.93; P=0.007). Diabetes developed in 73 patients (3.8%) and 149 patients (7.7%), respectively (hazard ratio, 0.48; 95% CI, 0.33 to 0.69; P<0.001). There was no significant between-group difference in all-cause mortality (hazard ratio, 0.93; 95% CI, 0.73 to 1.17; P=0.52). Pioglitazone was associated with a greater frequency of weight gain exceeding 4.5 kg than was placebo (52.2% vs. 33.7%, P<0.001), edema (35.6% vs. 24.9%, P<0.001), and bone fracture requiring surgery or hospitalization (5.1% vs. 3.2%, P=0.003). CONCLUSIONS: In this trial involving patients without diabetes who had insulin resistance along with a recent history of ischemic stroke or TIA, the risk of stroke or myocardial infarction was lower among patients who received pioglitazone than among those who received placebo. Pioglitazone was also associated with a lower risk of diabetes but with higher risks of weight gain, edema, and fracture. (Funded by the National Institute of Neurological Disorders and Stroke; ClinicalTrials.gov number, NCT00091949.).

Cancer and Cerebrovascular Disease.

PURPOSE OF REVIEW: To review the latest information about the interactions between cancer and cerebrovascular disease. RECENT FINDINGS: Additional data support the finding that both ischemic and hemorrhagic stroke are important complications of cancer or its treatment. Reperfusion therapy is being given successfully to patients with stroke complicating cancer. Hemorrhagic stroke may occur with metastatic disease to the brain, coagulopathies from cancer, in particular leukemia, or as complications of chemotherapy. Ischemic stroke also may be a complication of metastatic disease with local invasion of vessels, a pro-thrombotic disorder such as non-bacterial thrombotic endocarditis (NBTE) or disseminated intravascular coagulation (DIC), or secondary to chemotherapy. Stroke also is a potential consequence of radiation therapy to the head and neck. Venous sinus thrombosis may develop with hematologic malignancies or chemotherapy. Although many patients will have a history of cancer at the time of stroke, a cerebrovascular event may be the initial manifestation of a malignancy.

Secular Increases in Spontaneous Subarachnoid Hemorrhage during Pregnancy: A Nationwide Sample Analysis.

IMPORTANCE: Understanding of the epidemiology, outcomes, and management of spontaneous subarachnoid hemorrhage (sSAH) during pregnancy is limited. Small, single center series suggest a slight increase in morbidity and mortality. OBJECTIVE: To determine if incidence of sSAH in pregnancy is increasing nationally and also to study the outcomes for this patient population. DESIGN, SETTING, AND PARTICIPANTS: A retrospective analysis was performed utilizing the Nationwide Inpatient Sample (NIS) and Healthcare Cost and Utilization Project for the years 2002-2014 for sSAH hospitalizations. The NIS is a large administrative database designed to produce nationally weighted estimates. Female patients age 15-49 with sSAH were identified using the International Classification of Diseases, 9th Revision, Clinical Modification code 430. Pregnancy and maternal diagnosis were identified using pregnancy related ICD codes validated by previous studies. The Cochran-Armitage trend test and parametric tests were utilized to analyze temporal trends and group comparisons. Main Outcomes and Measures: National trend for incidence of sSAH in pregnancy, age, and race/ethnicity as well as associated risk factors and outcomes. RESULTS: During the time period, there were 73,692 admissions for sSAH in women age 15-49 years, of which 3978 (5.4%) occurred during pregnancy. The proportion of sSAH during pregnancy hospitalizations increased from 4.16 % to 6.33% (P-Trend < .001) during the 12 years of the study. African-American women (8.19%) and Hispanic (7.11%) had higher rates of sSAH during pregnancy than whites (3.83%). In the NIS data, the incidence of sSAH increased from 5.4/100,000 deliveries (2002) to 8.5/100,000 deliveries (2014; P-Trend < .0001). The greatest increase in sSAH was noted to be among pregnant African-American women from (13.4 [2002]) to (16.39 [2014]/100,000 births). Mortality was lower in pregnant women (7.69% versus 17.37%, P < .0001). Pregnant women had a higher likelihood of being discharged to home (69.78% versus 53.66%, P < .0001) and lower likelihood of discharge to long term facility (22.4% versus 28.7%, P < .0001) than nonpregnant women after sSAH hospitalization. CONCLUSIONS AND RELEVANCE: There is an upward trend in the incidence of sSAH occurring during pregnancy. There was disproportionate increase in incidence of sSAH in the African American and younger mothers. Outcomes were better for both pregnant and nonpregnant women treated at teaching hospitals and in pregnant women in general as compared to nonpregnant women.

Thrombolytic removal of intraventricular haemorrhage in treatment of severe stroke: results of the randomised, multicentre, multiregion, placebo-controlled CLEAR III trial.

BACKGROUND: Intraventricular haemorrhage is a subtype of intracerebral haemorrhage, with 50% mortality and serious disability for survivors. We aimed to test whether attempting to remove intraventricular haemorrhage with alteplase versus saline irrigation improved functional outcome. METHODS: In this randomised, double-blinded, placebo-controlled, multiregional trial (CLEAR III), participants with a routinely placed extraventricular drain, in the intensive care unit with stable, non-traumatic intracerebral haemorrhage volume less than 30 mL, intraventricular haemorrhage obstructing the 3rd or 4th ventricles, and no underlying pathology were adaptively randomly assigned (1:1), via a web-based system to receive up to 12 doses, 8 h apart of 1 mg of alteplase or 0·9% saline via the extraventricular drain. The treating physician, clinical research staff, and participants were masked to treatment assignment. CT scans were obtained every 24 h throughout dosing. The primary efficacy outcome was good functional outcome, defined as a modified Rankin Scale score (mRS) of 3 or less at 180 days per central adjudication by blinded evaluators. This study is registered with ClinicalTrials.gov, NCT00784134. FINDINGS: Between Sept 18, 2009, and Jan 13, 2015, 500 patients were randomised: 249 to the alteplase group and 251 to the saline group. 180-day follow-up data were available for analysis from 246 of 249 participants in the alteplase group and 245 of 251 participants in the placebo group. The primary efficacy outcome was similar in each group (good outcome in alteplase group 48% vs saline 45%; risk ratio [RR] 1·06 [95% CI 0·88-1·28; p=0·554]). A difference of 3·5% (RR 1·08 [95% CI 0·90-1·29], p=0·420) was found after adjustment for intraventricular haemorrhage size and thalamic intracerebral haemorrhage. At 180 days, the treatment group had lower case fatality (46 [18%] vs saline 73 [29%], hazard ratio 0·60 [95% CI 0·41-0·86], p=0·006), but a greater proportion with mRS 5 (42 [17%] vs 21 [9%]; RR 1·99 [95% CI 1·22-3·26], p=0·007). Ventriculitis (17 [7%] alteplase vs 31 [12%] saline; RR 0·55 [95% CI 0·31-0·97], p=0·048) and serious adverse events (114 [46%] alteplase vs 151 [60%] saline; RR 0·76 [95% CI 0·64-0·90], p=0·002) were less frequent with alteplase treatment. Symptomatic bleeding (six [2%] in the alteplase group vs five [2%] in the saline group; RR 1·21 [95% CI 0·37-3·91], p=0·771) was similar. INTERPRETATION: In patients with intraventricular haemorrhage and a routine extraventricular drain, irrigation with alteplase did not substantially improve functional outcomes at the mRS 3 cutoff compared with irrigation with saline. Protocol-based use of alteplase with extraventricular drain seems safe. Future investigation is needed to determine whether a greater frequency of complete intraventricular haemorrhage removal via alteplase produces gains in functional status. FUNDING: National Institute of Neurological Disorders and Stroke.

Mechanical Thrombectomy: Emerging Technologies and Techniques.

BACKGROUND: The treatment of acute ischemic stroke due to large vessel occlusion (LVO) has revolutionized in the last decade. We sought to compile the most relevant literature published about the evolution in treating this disabling and fatal disease. METHODS: A literature review of recent studies describing early treatment options like intravenous tissue plasminogen activator to the latest mechanical thrombectomy (MT) techniques was performed. We described in a chronological order the evolution of LVO treatment. RESULTS: Recanalization rates with newer techniques and MT devices approach a 90% of effectiveness. Timely interventions have also resulted in better clinical outcomes with approximately 50% of patient achieving functional independence at 90 days. At least 14 new third generation thrombectomy devices are currently being evaluated in in vitro and clinical studies. CONCLUSIONS: The treatment of LVO with MT is feasible and safe. MT is standard of care in treating acute ischemic stroke due to LVO.

Spinal Cord Hemorrhage.

BACKGROUND AND PURPOSE: Spinal cord hemorrhages are rare conditions that can be classified based on the primary location of bleeding into intramedullary (hematomyelia), subarachnoid hemorrhage (SAH), subdural hemorrhage, and epidural hemorrhage. We conducted a literature review to better understand the presenting symptoms, etiology, diagnosis, and treatment of spinal cord hemorrhages. METHODS: We performed a literature search using PubMed with the key words spinal hemorrhage, hematomyelia, spinal subarachnoid hemorrhage, spinal subdural hematoma, and spinal epidural hematoma RESULTS: Most commonly, spinal hematomas present with acute onset of pain and myelopathy but a more insidious course also may occur. Spinal SAH may be especially difficult as it may cause cerebral symptoms. The etiologies vary based on the type (location). The most common causes are trauma, iatrogenic causes, vascular malformations, and bleeding diatheses. Management is often aimed toward rapid surgical decompression and correction of the underlying etiology if possible. Conservative management, including administration of large doses of corticosteroids, reversal of anticoagulation, and close monitoring, has been used as bridging for surgical procedure or as the mainstay of treatment for patients with mild or improving symptoms. CONCLUSIONS: The variable and overlapping presentations of spinal cord hemorrhages make the diagnosis challenging. Maintaining high levels of clinical suspicion and utilizing magnetic resonance imaging may help in making the right diagnosis. Future studies should aim to create standardized outcome grading system and management guidelines for patients with spinal hemorrhage.

Intracranial Large and Medium Artery Atherosclerotic Disease and Stroke.

BACKGROUND: Intracranial atherosclerotic disease (ICAD) is one of the most common causes of stroke worldwide and is associated with a high risk of stroke recurrence. We sought to perform a literature review of the epidemiology, pathophysiology, and treatment options. METHODS: A literature review on recent studies evaluating the epidemiology, risk factors, clinical presentation, and treatment was reviewed. ICAD is particularly common in Africa and Asia. RESULTS: Although the medical management of ICAD has improved over the past decade, a subgroup of patients with ICAD remains at significantly high risk of stroke recurrence, and newer studies that aim at improving our understanding of ICAD and evaluating new treatment methods are currently under way. CONCLUSION: ICAD remains a common cause of stroke worldwide; further studies evaluating treatment options to prevent stroke recurrence are urgently needed.

Cerebral Microbleeds are an Independent Predictor of Hemorrhagic Transformation Following Intravenous Alteplase Administration in Acute Ischemic Stroke.

BACKGROUND AND PURPOSE: Intravenous alteplase (rt-PA) increases the risk of hemorrhagic transformation of acute ischemic stroke. The objective of our study was to evaluate clinical, laboratory, and imaging predictors on forecasting the risk of hemorrhagic transformation following treatment with rt-PA. We also evaluated the factors associated with cerebral microbleeds that increase the risk of hemorrhagic transformation. METHODS: Consecutive patients with acute ischemic stroke admitted between January 1, 2009 and December 31, 2013 were included in the study if they received IV rt-PA, had magnetic resonance imaging (MRI) of the brain on admission, and computed tomography or MRI of the brain at 24 (18-36) hours later to evaluate for the presence of hemorrhagic transformation. The clinical data, lipid levels, platelet count, MRI, and computed tomography images were retrospectively reviewed. RESULTS: The study included 366 patients, with mean age 67 ± 15 years; 46% were women and 88% were white. The median National Institutes of Health Stroke Scale (NIHSS) score was 6 (interquartile range 3-15). Hemorrhagic transformation was observed in 87 (23.8%) patients and cerebral microbleeds were noted in 95 (25.9%). Patients with hemorrhagic transformation tended to be older, nonwhite, have atrial fibrillation, higher baseline NIHSS score, lower cholesterol and triglyceride levels, and cerebral microbleeds and nonlacunar infarcts. Patients with cerebral microbleeds were more likely to be older, have hypertension, hyperlipidemia, previous history of stroke, and prior use of antithrombotics. On multivariate analysis race, NIHSS score, nonlacunar infarct, and presence of cerebral microbleeds were independently associated with hemorrhagic transformation following treatment with rt-PA. CONCLUSIONS: Presence of cerebral microbleeds is an independent predictor of hemorrhagic transformation of acute ischemic stroke following treatment with rt-PA.

Management of patients with stroke: is it time to expand treatment options?

Approximately 700,000 people in the United States have an ischemic stroke annually. Substantial research has tested therapies for the very early treatment of ischemic stroke but, to date, only intravenous thrombolysis and intra-arterial measures to restore perfusion have shown success. Despite a 15-year effort to increase the use of these therapies, only approximately 5% of patients with stroke are currently being treated. Although most patients with stroke have some neurological recovery, more than half of stroke survivors have residual impairments that lead to disability or long-term institutionalized care. Laboratory research has demonstrated several mechanisms that help the brain to recover after a stroke. New pharmacological and cell-based approaches that are known to promote brain plasticity are emerging from laboratory studies and may soon expand the window for stroke treatment to restore function. It is time to build on this knowledge and to translate the understanding of recovery after stroke into the clinical setting. Measures that might augment recovery should become a major focus of clinical research in stroke in the 21st century.

The safety of aeroplane travel in patients with symptomatic carotid occlusion.

OBJECTIVE: Patients with carotid stenosis or occlusion may be at increased risk for stroke during air travel. Records from the Carotid Occlusion Surgery Study (COSS), a randomised trial of surgical revascularisation for complete carotid artery occlusion and haemodynamic ischaemia, were examined for evidence of stroke related to air travel. METHODS: COSS subjects who travelled by aeroplane to a regional Positron Emission Tomography (PET) centre for a screening of cerebrovascular haemodynamic evaluation were identified. Maximum altitude and total flight time were estimated based on the distance between origin and destination. Ischaemic events were determined by a structured telephone interview within 24 h of travel. Patient demographics, comorbidities, oxygen extraction fraction (OEF) data and 24 h interview responses were recorded. RESULTS: Seventy-seven patients with symptomatic carotid occlusion travelled by aeroplane to a single PET centre (174 flights). Fifty-two (67.5%) were men and 25 (32.5%) were women. The average age was 58.7±1.4 years. Twenty-seven patients (35.1%) demonstrated evidence of ipsilateral haemodynamic cerebral ischaemia as measured by PET OEF, while 50 (64.9%) had normal OEF. Patients flew an average distance of 418.9±25.9 miles for 107.1±4.7 min per trip. No patient reported symptoms of a transient ischaemic attack or stroke during or within 24 h after aeroplane travel (95% CI 0% to 2.0%). CONCLUSIONS: The risk of stroke as a consequence of air travel is low, even in a cohort of patients at high risk for future stroke owing to haemodynamic impairment. These patients with symptomatic carotid occlusion should not be discouraged from air travel.

Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.

BACKGROUND AND PURPOSE: The authors present an overview of the current evidence and management recommendations for evaluation and treatment of adults with acute ischemic stroke. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators responsible for the care of acute ischemic stroke patients within the first 48 hours from stroke onset. These guidelines supersede the prior 2007 guidelines and 2009 updates. METHODS: Members of the writing committee were appointed by the American Stroke Association Stroke Council's Scientific Statement Oversight Committee, representing various areas of medical expertise. Strict adherence to the American Heart Association conflict of interest policy was maintained throughout the consensus process. Panel members were assigned topics relevant to their areas of expertise, reviewed the stroke literature with emphasis on publications since the prior guidelines, and drafted recommendations in accordance with the American Heart Association Stroke Council's Level of Evidence grading algorithm. RESULTS: The goal of these guidelines is to limit the morbidity and mortality associated with stroke. The guidelines support the overarching concept of stroke systems of care and detail aspects of stroke care from patient recognition; emergency medical services activation, transport, and triage; through the initial hours in the emergency department and stroke unit. The guideline discusses early stroke evaluation and general medical care, as well as ischemic stroke, specific interventions such as reperfusion strategies, and general physiological optimization for cerebral resuscitation. CONCLUSIONS: Because many of the recommendations are based on limited data, additional research on treatment of acute ischemic stroke remains urgently needed.

The NIHSS supplementary motor scale: a valid tool for multidisciplinary recovery trials.

BACKGROUND: There is a growing interest in therapies that may augment motor recovery that could be initiated in the acute stroke unit and maintained through the rehabilitation period. Homogenization of the currently fragmented stroke clinicometrics is necessary before such multidisciplinary trials can be conducted. The supplementary motor scale of the NIH Stroke Scale (SMS-NIHSS) is a simple and reliable scale for assessing proximal and distal motor function in the upper and lower extremities. We hypothesized that the currently underutilized SMS-NIHSS is a valid tool for assessing motor recovery with prognosticative value. METHODS: We performed an analysis of SMS-NIHSS scores recorded in 1,281 patients enrolled in the Trial of ORG 10172 in Acute Stroke Treatment (TOAST). We plotted the probability of a favorable outcome (FO) and very favorable outcome (VFO) at 3 months based on the baseline SMS-NIHSS scores. In order to better study the relationship between SMS-NIHSS and 3-month functional outcome, we performed multivariate logistic regression analyses using both FO and VFO as outcome measures. Analyses were adjusted for potential confounders such as age, sex, side of the lesion, time from symptom onset to emergency room arrival, temperature, systolic blood pressure, blood glucose level and treatment group assignment (ORG 10172 vs. placebo). We also calculated the Spearman correlation coefficient between the SMS-NIHSS, Barthel Index (BI) and Glasgow Outcome Score (GOS) obtained at the 3-month visit. RESULTS: The mean SMS-NIHSS scores were 8.18 at baseline and 4.68 at 3 months. The SMS-NIHSS scores showed a gradual improvement during the first 3 months after stroke. There was a linear relationship between the baseline SMS-NIHSS scores and the probability of an FO or VFO at 3 months. The SMS-NIHSS baseline score was an independent predictor of FO (OR = 0.86; 95% CI 0.84-0.87; p < 0.0001) and VFO (OR = 0.85; 95% CI 0.84-0.87; p < 0.0001) at 3 months after adjusting for confounders. The degree of improvement in the SMS-NIHSS scores from baseline to 3 months was also independently associated with FO and VFO (p < 0.0001). At 3 months, SMS-NIHSS scores showed a strong correlation with the BI (r = -0.70; p < 0.0001) and GOS (r = 0.73; p < 0.0001). CONCLUSIONS: The SMS-NIHSS is a valid scale for assessing motor recovery with prognosticative value, and may be sensitive to changes during recovery. Given that the SMS-NIHSS is an extension of the widely accepted NIHSS, it could be easily implemented in trials conducted in a variety of clinical research settings, including acute stroke hospitals and rehabilitation units.