Quantification of pial collateral pressure in acute large vessel occlusion stroke: basic concept with patient outcomes.

PURPOSE: Pial collateral perfusion to the ischemic penumbra plays a critical role in determining patient outcomes in acute stroke. We aimed to assess the validity and reliability of an intra-procedural technique for measuring and quantifying the pial collateral pressure (QPCP) to ischemic brain tissue during acute stroke secondary to LVO. QPCP measurements were correlated with standard computed tomography angiography (CTA) and digital subtraction angiography imaging assessments of pial collateral perfusion and outcomes after mechanical endovascular revascularization (MER). METHODS: This prospective cohort study included 60 consecutive patients with middle cerebral artery (MCA)-M1 and proximal M2 occlusions. QPCP measurements were obtained during MER. The validity of QPCP measurements was evaluated using four widely accepted collateral grading scales. QPCP measurements were also analyzed as a predictor of patient outcomes utilizing National Institute of Health Stroke Scale reduction at 24 h and modified Rankin Scale (mRS) scores at 30 days. RESULTS: QPCP measurements and QPCP ratio (QPCP/systemic mean arterial blood pressure) showed a statistically significant association with single-phase pretreatment CTA Maas and American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology binary grading scales. Patient outcomes demonstrated for every 10-unit increase in QPCP, the odds of mRS 0-2 at 30 days increased by 76% (p = 0.019). CONCLUSION: QPCP measurements related best with the pretreatment CTA Maas collateral grading scale but were more strongly associated with patient outcomes than any of the four widely accepted collateral grading scales. Greater QPCP was significantly associated with better overall patient outcomes as defined by mRS at 30 days.

Impact of the COVID-19 Pandemic on Acute Stroke Care, Time Metrics, Outcomes, and Racial Disparities in a Southeast Michigan Health System.

BACKGROUND: COVID-19 has impacted acute stroke care with several reports showing worldwide drops in stroke caseload during the pandemic. We studied the impact of COVID-19 on acute stroke care in our health system serving Southeast Michigan as we rolled out a policy to limit admissions and transfers. METHODS: in this retrospective study conducted at two stroke centers, we included consecutive patients presenting to the ED for whom a stroke alert was activated during the period extending from 3/20/20 to 5/20/20 and a similar period in 2019. We compared demographics, time metrics, and discharge outcomes between the two groups. RESULTS: of 385 patients presented to the ED during the two time periods, 58% were African American. There was a significant decrease in the number of stroke patients presenting to the ED and admitted to the hospital between the two periods (p <0.001). In 2020, patients had higher presenting NIHSS (median: 2 vs 5, p = 0.012), discharge NIHSS (median: 2 vs 3, p = 0.004), and longer times from LKW to ED arrival (4.8 vs 9.4 h, p = 0.031) and stroke team activation (median: 10 vs 15 min, p = 0.006). In 2020, stroke mimics rates were lower among African Americans. There were fewer hospitalizations (p <0.001), and transfers from outside facilities (p = 0.015). CONCLUSION: a trend toward faster stroke care in the ED was observed during the pandemic along with dramatically reduced numbers of ED visits, hospitalizations and stroke mimics. Delayed ED presentations and higher stroke severity characterized the African American population, highlighting deepening of racial disparities during the pandemic.

CTA-for-All: Impact of Emergency Computed Tomographic Angiography for All Patients With Stroke Presenting Within 24 Hours of Onset.

Background and Purpose- We sought to evaluate the impact of a Computed Tomographic Angiography (CTA) for All emergency stroke imaging protocol on outcome after large vessel occlusion (LVO). Methods- On July 1, 2017, the Henry Ford Health System implemented the policy of performing CTA and noncontrast computed tomography together as an initial imaging study for all patients with acute ischemic stroke (AIS) presenting within 24 hours of last known well, regardless of baseline National Institutes of Health Stroke Scale score. Previously, CTA was reserved for patients presenting within 6 hours with a National Institutes of Health Stroke Scale score ≥6. We compared treatment processes and outcomes between patients with AIS admitted 1 year before (n=388) and after (n=515) protocol implementation. Results- After protocol implementation, more AIS patients underwent CTA (91% versus 61%; P<0.001) and had CTA performed at the same time as the initial noncontrast computed tomography scan (78% versus 35%; P<0.001). Median time from emergency department arrival to CTA was also shorter (29 [interquartile range, 16-53] versus 43 [interquartile range, 29-112] minutes; P<0.001), more cases of LVO were detected (166 versus 96; 32% versus 25% of all AIS; P=0.014), and more mechanical thrombectomy procedures were performed (108 versus 68; 21% versus 18% of all AIS; P=0.196). Among LVO patients who presented within 6 hours of last known well, median time from last known well to mechanical thrombectomy was shorter (3.5 [interquartile range, 2.8-4.8] versus 4.1 [interquartile range, 3.3-5.6] hours; P=0.038), and more patients were discharged with a favorable outcome (Glasgow Outcome Scale 4-5, 53% versus 37%; P=0.029). The odds of having a favorable outcome after protocol implementation was not significant (odds ratio, 1.84 [95% CI, 0.98-3.45]; P=0.059) after controlling for age and baseline National Institutes of Health Stroke Scale score. Conclusions- Performing CTA and noncontrast computed tomography together as an initial assessment for all AIS patients presenting within 24 hours of last known well improved LVO detection, increased the mechanical thrombectomy treatment population, hastened intervention, and was associated with a trend toward improved outcome among LVO patients presenting within 6 hours of symptom onset.

Transcatheter closure of patent foramen ovale for secondary prevention of ischemic stroke: Quantitative synthesis of pooled randomized trial data.

OBJECTIVES: To evaluate the safety and efficacy of percutaneous device closure of patent foramen ovale (PFO) for secondary prevention of ischemic stroke BACKGROUND: Stroke remains the leading cause of serious long-term disability in the United States. The effectiveness of a percutaneous PFO closure in the prevention of recurrent cryptogenic strokes has not been established. METHODS: We performed a literature search using PubMed, EMBASE, Cochrane Central Register of Controlled Trials, Google Scholar, and Internet-based sources from January 2003 to September 2017. Randomized controlled trails (RCTs) comparing percutaneous PFO closure to medical therapy alone. RESULTS: Five RCTs (CLOSURE I, PC Trial, REDUCE, RESPECT, and CLOSE) with 1,829 patients in the device group and 1,611 patients in the medical group met inclusion criteria. The cumulative incidence of recurrent stroke was 2.02% in the PFO closure arm and 4.4% in the medical therapy group (RR 0.42, 95%CI 0.20, 0.91; P = 0.03). There was no difference in the incidence of death [0.7% vs. 0.9%; RR 0.76 (95% CI 0.35, 1.64), P = 0.49] or adverse events during the follow-up period [24.6% vs. 23.7% (RR 1.03; 95% CI 0.91, 1.16), P = 0.65] between the closure and medical therapy groups. Incidence of atrial fibrillation was significantly higher in closure group compared to medical therapy [4% vs. 0.6% (RR 4.73; 95% CI 2.09, 10.70), P = 0.0002]. The comparative effectiveness of PFO closure (compared to medical therapy) was significantly more pronounced in those younger than 45 years, males, larger shunts and disc design platforms (P < 0.05). CONCLUSIONS: Based on the results of this analysis of randomized trial data, percutaneous PFO closure appears to be a safe and effective therapeutic option for the secondary prevention of ischemic stroke in patients with PFO and cryptogenic stroke.

Rituximab for prevention of strokes in cerebral rheumatoid vasculitis.

Rheumatoid arthritis (RA) is an autoimmune disorder which manifests as inflammation of the synovial joints alongside extra-articular involvement. Uncommonly, patients may develop vasculitis of small and medium-sized blood vessels, formally diagnosed as systemic rheumatoid vasculitis (SRV). In particularly rare cases, patients may develop a subtype of SRV known as cerebral rheumatoid vasculitis (CRV) which manifests in patients as stroke. To date, no formal recommendations or guidelines have been established for treatment and prevention of CRV-induced stroke besides experiential therapy with various immunomodulators. Here, we describe the utility of Rituximab in addition to steroids for prevention of stroke in our patient with evidence of multiple CRV-induced strokes with excellent recovery of post-stroke symptoms and remission of new onset cerebral vasculitis processes.

Moyamoya syndrome associated with Graves' disease: a case report and review of the literature.

We report a patient and critically review the literature in order to define the demographic, clinical, neuroradiologic, and treatment features of moyamoya syndrome (MMS) in the setting of Graves' disease (GD). We performed a comprehensive English language Medline search using the keywords "moyamoya," "Graves' disease," and "thyrotoxicosis." We included all patients with angiographic findings consistent with MMS. A 23-year-old woman with active GD presented with intermittent confusion and right arm paresis. Brain magnetic resonance imaging revealed acute left and chronic bilateral hemispheric infarcts. Cerebral angiography revealed multivessel intracranial occlusive disease. Initial treatment with plasmapheresis plus aspirin stabilized the patient's neurologic deficits. Antithyroid treatment plus subsequent surgical encephalomyosynangiosis resulted in prolonged neurologic stability. We studied 30 patients (27 women [90%], 23 of Asian descent [77%]), with a mean age of 29 ± 11.6 years. Hemiparesis (n = 12; 40%) was the leading clinical sign, and ischemic infarction was the most frequent neuroimaging finding (n = 26; 87%). Treatment regimens included antithyroid medications alone (n = 5; 17%), antithyroid plus antiplatelet agents (n = 9; 30%), neurosurgical revascularization after antithyroid medication (n = 11; 37%), and plasmapheresis in the acute thyrotoxic state (n = 2; 7%). Most patients had good short-to-medium term outcome (n = 14; 78% of reported outcome). Plasmapheresis-treated patients achieved neurologic stabilization and had good outcomes. MMS, an infrequent complication of GD, typically affects young women. Our findings indicate that plasmapheresis can stabilize the neurologic picture in the acute phase, and that antithyroid and antiplatelet therapy, combined with revascularization surgery, may improve long-term outcomes. Further work is needed to establish an optimal treatment strategy.

Tales of a department: how the COVID-19 pandemic transformed Detroit's Henry Ford Hospital, Department of Neurology-part I: the surge.

The COVID-19 pandemic has reshaped the way healthcare systems operate around the world. The major hurdles faced have been availability of personal protective equipment, intensive care unit beds, ventilators, treatments and medical personnel. Detroit, Michigan has been an epidemic 'hotspot' in the USA with Wayne County among the hardest hit counties in the nation. The Department of Neurology at Henry Ford Hospital, in the heart of Detroit, has responded effectively to the pandemic by altering many aspects of its operations. The rapid engagement of the department and enhanced utilisation of teleneurology were two of the pivotal elements in the successful response to the pandemic. In this review, we describe the transformation our department has undergone, as it relates to its infrastructure redesigning, coverage restructuring, redeployment strategies, medical education adaptations and novel research initiatives.

Periictal diffusion abnormalities of the thalamus in partial status epilepticus.

PURPOSE: To identify and describe thalamic dysfunction in patients with temporal as well as extratemporal status epilepticus (SE) and to also analyze the specific clinical, radiological, and electroencephalography (EEG) characteristics of patients with acute thalamic involvement. METHODS: We retrospectively identified patients who presented with clinical and electrographic evidence of partial SE and had thalamic abnormalities on diffusion-weighted imaging (DWI) within 5 days of documentation of lateralized epileptiform discharges (group 1). The spatial and temporal characteristics of the periodic lateralized epileptiform discharges (PLEDs) and the recorded electrographic seizures were analyzed and correlated with magnetic resonance imaging (MRI)-DWI hyperintense lesions. The findings of group 1 patients were compared with those of patients with partial SE without thalamic abnormalities on DWI (group 2). RESULTS: The two groups were similar with regard to clinical presentation and morphology of epileptiform discharges. Group 1 patients had thalamic hyperintense lesions on DWI that appeared in the region of the pulvinar nucleus, ipsilateral to the epileptiform activity. Statistically significant relationship was noted between the presence of thalamic lesions and ipsilateral cortical laminar involvement (p = 0.039) as well as seizure origin in the posterior quadrants (p = 0.038). A trend towards PLEDs originating in the posterior quadrants was also noted (p = 0.077). DISCUSSION: Thalamic DWI hyperintense lesions may be observed after prolonged partial SE and are likely the result of excessive activity in thalamic nuclei having reciprocal connections with the involved cortex. The thalamus likely participates in the evolution and propagation of partial seizures in SE.

Sildenafil treatment of subacute ischemic stroke: a safety study at 25-mg daily for 2 weeks.

BACKGROUND: In several animal studies of young and aged rats with ischemic stroke, treatment with sildenafil improved functional outcomes compared with placebo. We conducted a safety study of sildenafil (25 mg daily for 2 weeks) shortly after ischemic stroke onset. METHODS: We recruited patients aged 18 to 80 years with ischemic stroke, National Institutes of Health stroke scale (NIHSS) score 2 to 21, between days 2 and 9 after symptom onset. Patients were treated with sildenafil for 2 weeks (25 mg daily). The primary outcome measure was the adverse occurrence of any of the following during the treatment period: stroke worsening, new stroke, myocardial infarction, vision loss, hearing loss, or death from any cause. Secondary outcome measures were NIHSS score, Barthel indices, and modified Rankin score at 90 days. RESULTS: Twelve patients were recruited. Mean age was 57 years, 5 were female, and median NIHSS score at entry was 9.5 (range 2-20). The primary outcome measure occurred in one patient (sudden death). Another patient committed suicide 2 months after study entry (and 6 weeks after treatment with sildenafil had been completed). Among the 10 survivors, at 90 days, median NIHSS score was 2 (range 0-12), median Barthel index was 95 (range 15-100), and median modified Rankin score was 1.5 (range 0-5). CONCLUSIONS: Sildenafil (25 mg daily for 2 weeks) appeared to be safe in this group of patients with mild to moderately severe stroke. Further studies of higher doses will be tested.

Atrial fibrillation, not atrial cardiopathy, is associated with stroke: A single center retrospective study.

BACKGROUND: Atrial fibrillation (AF) increases the risk of thromboembolism. Atrial cardiopathy, defined as structural left atrial enlargement (LAE), has been proposed to be a unifying risk factor for stroke, with or without atrial fibrillation (AF). We sought to understand the relative importance of LAE and AF as risk factors for stroke. METHODS: We performed a retrospective analysis of all patients who underwent echocardiography within the Henry Ford Health System between March and September 2016. Patients were categorized based on the degree of LAE (none, mild, moderate and severe). The diagnosis of prior stroke or AF was ascertained by the presence of these conditions in the electronic medical record (www.EPIC.com). RESULTS: Total of 8679 cases, 54% were female, 41% were African-American, and mean age was 65 ±â€¯17 years. Fifteen percent had mild, 12% had moderate and 18% had severe LAE; the frequency of AF was 22%; and prior stroke was 18%. In multivariate analysis, the odds of AF increased progressively with severity of LAE (adjusted OR for mild 1.81, moderate 2.13 and severe 4.38, all P < .001) and AF was confirmed as a risk factor for prior stroke (aOR 1.34, CI 1.15-1.56, p < .001). By contrast, there was no association between LAE and stroke (aOR 0.98 CI 0.86-1.12, p = .74), regardless of the severity of LAE, and regardless of whether AF was present or not. CONCLUSION: Structural LAE, found in almost half of this population, has a significant association with AF. While AF was confirmed to have a significant association with prior stroke, we found no association between stroke and LAE. AF, not LAE, appears to be the true atrial factor associated with stroke.

What to Look for on Post-stroke Neuroimaging.

The most feared complication after acute ischemic stroke is symptomatic or asymptomatic hemorrhagic conversion. Neuroimaging and clinical criteria are used to predict development of hemorrhage. Seizures after acute ischemic stroke or stroke-like symptoms from seizures are not common but may lead to confusion in the peristroke period, especially if seizures are repetitive or evolve into status epilepticus, which could affect neuroimaging findings. Malignant infarction develops when cytotoxic edema is large enough to lead to herniation and death. Post-stroke neuroimaging prognosticators have been described and should be assessed early so that appropriate treatment is offered before herniation leads to additional tissue injury.

Safety and Efficacy of Stent Retrievers for the Management of Acute Ischemic Stroke: Comprehensive Review and Meta-Analysis.

OBJECTIVES: This study sought to evaluate the safety and efficacy of stent retriever for the management of acute ischemic stroke. BACKGROUND: Stroke is the third leading cause of death and the most common cause of disability in the United States. Early reperfusion has been associated with favorable outcomes. Stent retrievers are novel endovascular devices that provide vessel recanalization via thrombus retrieval mechanical thrombectomy. METHODS: The authors performed a literature search using PubMed, EMBASE, and Cochrane Central Register of Controlled Trials from May 2005 to May 2015. Randomized controlled trails (RCTs) comparing endovascular therapy (ET) with the use of retrievable stents against standard therapy (ST) for the management of acute stroke were included. RESULTS: Five RCTs (the MR CLEAN, ESCAPE, EXTEND-IA, SWIFT-PRIME, and REVASCAT studies) with 634 patients in the ET group and 653 patients in the ST group met inclusion criteria. The frequency of a low 90-day modified Rankin Score (0 to 2) in the intervention group was 42.6% compared with 26.1% in the control group (odds ratio: 2.43; 95% confidence interval [CI]: 1.9 to 3.09; p < 0.0001). The frequency of intracranial bleeding was 4.2% in the ET group compared with 4.3% in the ST group (risk ratio: 1.08; 95% CI: 0.64 to 1.82; p = 0.78). 90-day mortality was 15.1% in the ET group compared with 18.7% in the ST group (risk ratio: 0.81; 95% CI: 0.58 to 1.12; p = 0.19). There was no evidence of significant heterogeneity or publication bias for any of the endpoints. CONCLUSIONS: On the basis of the results of this meta-analysis of RCTs, ET with stent retrievers appears as a safe and effective therapeutic option for acute ischemic stroke due to large vessel occlusion.

Acute effects of nicotine withdrawal syndrome in pilots during flight.

BACKGROUND: Pilots who smoke are occasionally obliged to abstain from nicotine intake during flight and may during this period exhibit certain symptoms leading to performance decrement. METHODS: We studied 20 healthy male aviators, who were regular smokers, (mean age 33.7 +/- 1.4 yr) operating military fixed- and rotary-wing aircraft (C-47 Dakota, F-16, A. Bell 205). All pilots were subjected to a 12-h abstinence from cigarette smoking, during which time they performed flight duties. After landing, we studied the intensity of the nicotine withdrawal syndrome, as well as its effect on physiological parameters, psychological functions, and cognitive tasks. This was achieved by the completion of a questionnaire, measurement of BP and heart rate, and the execution of certain computerized performance assessment tests. These tests measure mental arithmetic, visual vigilance, and image free-recall. In a subsequent flight performed under similar conditions, every pilot repeated the procedure without smoking deprivation. Thus, each subject served as his own control. The Wilcoxon non-parametric test was applied for statistical analysis. RESULTS: The most frequent symptoms reported during nicotine deprivation were nervousness, craving for tobacco, tension-anxiety, fatigue, difficulty in concentration, decrease in alertness, disorders of fine adjustments, prolonged reaction times, anger-irritability, drowsiness, increase in appetite, and impairment of judgement. Systolic BP and heart rate tended to decrease and diastolic BP tended to rise during withdrawal, although the differences were not statistically significant. Finally, all tests recorded an impairment of cognitive functions during abstinence. CONCLUSION: Abrupt cessation of smoking may be detrimental to flight safety and the smoking withdrawal syndrome may influence flying parameters.

Fibromuscular dysplasia unraveled: the pulsation-induced microtrauma and reactive hyperplasia theory.

INTRODUCTION: Fibromuscular dysplasia (FMD) is a relatively uncommon, non-inflammatory, non-atherosclerotic vascular condition of unknown etiology. There have been no major advancements in understanding FMD in the past 30-40yrs. We hypothesize that the vascular changes seen in FMD are a direct result of recurrent mechanical trauma in susceptible vessels and reflect a compensatory response to recurrent pulsation-induced mechanical trauma. METHODS: Radiology records at a large tertiary care medical center were queried for cases of cervical carotid FMD. Cases with viewable sequential angiographic evidence of FMD were selected and analyzed for degree of vessel tortuosity, FMD type, degree of vessel movement, and association with the FMD lesion. Images were independently analyzed by 1 neurologist and 2 neuroradiologists. RESULTS: Twenty-four carotid vessels in fourteen patients were identified to have FMD, 100% of patients were female, average age was 58.43±8.72yrs (range 45-73), 35.7% were black, 35.7% had HTN, 7.14% had CKD and 7.14% used tobacco in the past year. Associated findings included aneurysms and dissections. All but 1 patient had at least mild vessel tortuosity, and 28.6% were moderate or severe. All but 1 patient had at least "some" pulsation-like vessel movement, 16.7% had "significant" movement, and all movement was focally associated with the FMD abnormality. CONCLUSION: Pulsatile vascular movements were observed in high frequency and in high association with FMD. We propose a theoretical connection between the pulsation-induced movement and a process of reactive vascular hyperplasia and fibrosis responsible for the FMD phenotype and is consistent with previous findings.

Outpatient cardiac telemetry detects a high rate of atrial fibrillation in cryptogenic stroke.

BACKGROUND: The etiology of cerebral ischemia is undetermined in one-third of patients upon discharge. Occult paroxysmal atrial fibrillation (PAF) is considered a potential etiology. A high rate of PAF detection with 21-day mobile cardiac outpatient telemetry (MCOT) has been reported in two small studies. Optimal monitoring duration and factors predicting PAF have not been adequately defined. METHODS: We performed a retrospective analysis on patients evaluated by MCOT monitoring within 6 months of a cryptogenic stroke or TIA. Multivariate analysis with survival regression methods was performed using baseline characteristics to determine predictive risk factors for detection of PAF. Kaplan-Meier estimates were computed for 21-day PAF rates. RESULTS: We analyzed 156 records; PAF occurred in 27 of 156 (17.3%) patients during MCOT monitoring of up to 30 days. The rate of PAF detection significantly increased from 3.9% in the initial 48 h, to 9.2% at 7 days, 15.1% at 14 days, and 19.5% by 21 days (p<0.05). Female gender, premature atrial complex on ECG, increased left atrial diameter, reduced left ventricular ejection fraction and greater stroke severity were independent predictors of PAF detection on multivariate analysis with strongest correlation seen for premature atrial complex on ECG (HR 13.7, p=0.001). CONCLUSION: MCOT frequently detects PAF in patients with cryptogenic stroke and TIA. Length of monitoring is strongly associated with detection of PAF, with an optimal monitoring period of at least 21 days. Of the predictors of PAF detection, the presence of premature atrial complexes on ECG held the strongest correlation with PAF.

Urine toxicology screening in an urban stroke and TIA population.

OBJECTIVE: We sought to determine the rate of urine toxicology screening, differences in testing, and outcomes among patients with stroke and TIA presenting to a tertiary care emergency department. METHODS: In this retrospective cohort study, patients admitted with stroke or TIA to a single tertiary care stroke center between June 2005 and January 2007 were identified through a stroke database. Factors that predicted urine toxicology screening of patients and a positive test, and discharge outcomes of patients based on toxicology result were analyzed. Stroke severity, treatment with tissue plasminogen activator, discharge status, and stroke etiology were compared between toxicology positive and negative patients. RESULTS: A total of 1,024 patients were identified: 704 with ischemic stroke, 133 with intracerebral hemorrhage, and 205 with TIA. Urine toxicology screening was performed in 420 patients (40%); 11% of these studies were positive for cocaine (19% younger than 50 years and 9% 50 years or older). Factors that significantly predicted the performance of a urine toxicology screen were younger age (<50 years) and black race (<0.001). Positive toxicology screens occurred in a broad range of patients. There were no significant differences in admission NIH Stroke Scale score, stroke etiology, and discharge status between toxicology-positive and -negative patients. CONCLUSIONS: In this study, patients with stroke and TIA who were young and black were more likely to have urine toxicology screening. Eleven percent of all tested patients (and 9% of patients 50 years or older) were positive for cocaine. To avoid disparities, we suggest that all stroke and TIA patients be tested.

Creating accountable care for carotid angioplasty and stenting: A multidisciplinary carotid revascularization board.

BACKGROUND: We tested the feasibility of a mandated multidisciplinary carotid revascularization board (MDCB) to review, approve and monitor all carotid artery and stenting (CAS) procedures and outcomes at our institution. METHODS: The board was composed of vascular surgeons, cardiologists, interventional neuroradiologists, neurosurgeons, and neurologists, who met weekly to facilitate an evidence-based, consensus recommendation to ensure appropriate CAS referral. RESULTS: The board successfully reviewed and continues to review and approve all CAS procedures at our center. Of the 69 patients considered high risk for standard surgical treatment, 42 patients were symptomatic and 27 patients were asymptomatic. Their mean age was 70.5-year-old and the median degree of stenosis was 79%. In the 74 procedures, periprocedural complications occurred at the following rates: 2.7% death, 2.7% major stroke, 2.7% minor stroke, and 2.7% myocardial infarction (MI) within 30 days of the procedure. At 1 year the primary endpoints of ipsilateral stroke and neurovascular-related death were observed in 8.1% and 2.7% of the patients, respectively. At mean follow-up of 21 months, 18.8% of the patients (13/69) had died (including all causes), and 14.5% (10/69) experienced stroke (including nontarget strokes). Target vessel revascularization was needed in 2.9% patients. CONCLUSIONS: A mandated multidisciplinary carotid revascularization board MDCB is feasible and potentially advantageous in real clinical practice. It establishes a model for accountable care by providing a mechanism for institutional oversight, credentialing operators, quality review, standardizing care, cost containment and eliminating the "subspecialty silo mentality."

Development of a scoring system for atrial fibrillation in acute stroke and transient ischemic attack patients: the LADS scoring system.

INTRODUCTION: Detection of atrial fibrillation in patients presenting with ischemic stroke or transient ischemic attack (TIA) is important for the prevention of future events. We sought to develop a scoring system that would identify those patients most likely to have atrial fibrillation. METHODS: Records from an inpatient stroke and TIA database and echocardiographic data were reviewed. Consecutive acute stroke and TIA patients over the age of 18 who were admitted during a two-year period were studied. Univariate and multivariable analyses were performed to identify variables associated with atrial fibrillation. Logistic regression analyses were used to develop a scoring system for atrial fibrillation. RESULTS: 953 patient charts were reviewed; 145 patients (15%) had atrial fibrillation. In univariate and multivariate analyses, variables that were significantly associated with atrial fibrillation included left atrial diameter, age, and diagnosis of stroke. A history of smoking showed an inverse association. A 6-point scoring system based on these variables (with the acronym of LADS) was developed. A score of 4 or greater was associated with a sensitivity of 85.5% and a specificity of 53.1%. Approximately 47% of stroke and TIA patients would be excluded from further investigation using this score. CONCLUSIONS: We describe a system of scoring that identifies acute stroke and TIA patients with a greater chance of having atrial fibrillation. An inverse relationship with smoking was found. Further prospective studies are required to determine the clinical utility and cost-effectiveness of this scoring system in clinical practice and to investigate the inverse relationship between smoking and atrial fibrillation in this population.