Preservation of vision after CaMKII-mediated protection of retinal ganglion cells.

Retinal ganglion cells (RGCs) are the sole output neurons that transmit visual information from the retina to the brain. Diverse insults and pathological states cause degeneration of RGC somas and axons leading to irreversible vision loss. A fundamental question is whether manipulation of a key regulator of RGC survival can protect RGCs from diverse insults and pathological states, and ultimately preserve vision. Here, we report that CaMKII-CREB signaling is compromised after excitotoxic injury to RGC somas or optic nerve injury to RGC axons, and reactivation of this pathway robustly protects RGCs from both injuries. CaMKII activity also promotes RGC survival in the normal retina. Further, reactivation of CaMKII protects RGCs in two glaucoma models where RGCs degenerate from elevated intraocular pressure or genetic deficiency. Last, CaMKII reactivation protects long-distance RGC axon projections in vivo and preserves visual function, from the retina to the visual cortex, and visually guided behavior.

Post-Hospitalization Home Monitoring Programs During the COVID-19 Pandemic: Survey Results from the Hospital Medicine Re-engineering Network (HOMERuN).

BACKGROUND: During the coronavirus disease 2019 (COVID-19) pandemic, hospitals and healthcare systems launched innovative responses to emerging needs. The creation and use of programs to remotely follow patient clinical status and recovery after COVID-19 hospitalization has not been thoroughly described. OBJECTIVE: To characterize deployment of remote post-hospital discharge monitoring programs during the COVID-19 pandemic METHODS: Electronic surveys were administered to leaders of 83 US academic hospitals in the Hospital Medicine Re-engineering Network (HOMERuN). An initial survey was completed in March 2021 with follow-up survey completed in July 2022. RESULTS: There were 35 responses to the initial survey (42%) and 15 responses to the follow-up survey (43%). Twenty-two (63%) sites reported a post-discharge monitoring program, 16 of which were newly developed for COVID-19. Physiologic monitoring devices such as pulse oximeters were often provided. Communication with medical teams was often via telephone, with moderate use of apps or electronic medical record integration. Programs launched most commonly between January and June 2020. Only three programs were still active at the time of follow-up survey. CONCLUSIONS: Our findings demonstrate rapid, ad hoc development of post-hospital discharge monitoring programs during the COVID-19 pandemic but with little standardization or evaluation. Additional study could identify the benefits of these programs, instruct their potential application to other disease processes, and inform further development as part of emergency preparedness for upcoming crises.

Complications of Implanted Vagus Nerve Stimulation: A Systematic Review and Meta-analysis.

INTRODUCTION: Vagus Nerve Stimulation (VNS) has emerged as a promising tool in ischemic stroke rehabilitation. However, there has been no systematic review summarizing its adverse effects, critical information for patients and providers when obtaining informed consent for this novel treatment. This systematic review and meta-analysis reports the adverse effects of VNS. METHODS: A systematic review was performed in accordance with PRISMA guidelines to identify common complications after VNS therapy. The search was executed in: Cochrane Central Register of Controlled Trials, Embase, and Ovid MEDLINE. All prospective, randomized controlled trials using implanted VNS therapy in adult patients were eligible for inclusion. Case studies and studies lacking complete complication reports were excluded. Extracted data included technology name, location of implantation, follow-up duration, purpose of VNS, and adverse event rates. RESULTS: After title-and-abstract screening of 4933 studies, 21 were selected for final inclusion. Across these studies, 1474 patients received VNS implantation. VNS was used as a potential therapy for epilepsy (9), depression (8), anxiety (1), ischemic stroke (1), chronic heart failure (1), and fibromyalgia (1). The 5 most common post-implant adverse events were voice alteration/hoarseness (n=671, 45.5%), paresthesia (n = 233, 15.8%), cough (n = 221, 15.0%), dyspnea (n = 211, 14.3%), and pain (n = 170, 11.5%). CONCLUSIONS: Complications from VNS are mild and transient, with reduction in severity and number of adverse events with increasing follow-up time. In prior studies, VNS has served as treatment option in several instances of treatment-resistant conditions, such as epilepsy and psychiatric conditions, and its use in stroke recovery and rehabilitation should continue to be explored.

Antithrombotics alter intracerebral hemorrhage presentation without affecting minimally invasive endoscopic evacuation.

OBJECTIVES: Intracerebral hemorrhages are associated with significant morbidity and mortality. While the ENRICH trial supports the efficacy of surgical evacuation for lobar hemorrhages, the impact of antithrombotic therapies on minimally invasive surgery outcomes remains unexplored. This study evaluates the effects of chronic anticoagulants and antiplatelets on the technical and longterm outcomes of minimally invasive intracerebral hemorrhage evacuation. MATERIALS AND METHODS: A prospectively collected registry of patients undergoing minimally invasive surgery for intracerebral hemorrhage from a single institution was analyzed (December 2015-September 2022). Data included key demographics, comorbidities, antithrombotic/reversal status, presenting clinical/radiographic characteristics, procedural metrics, and clinical outcomes. Patients were divided into control (neither therapy), antiplatelet-only, and anticoagulant-only groups, with antiplatelet/anticoagulant reversals conducted per current American Heart Association/American Stroke Association guidelines. Variables significant in univariate analyses (p<0.05) were advanced to multivariable regression models. RESULTS: Among 226 intracerebral hemorrhage patients treated with minimally invasive surgery, 41% (N=93) had antithrombotic medication history; 28% (N=64) received antiplatelets, and 9% (N=21) received anticoagulants. Patients on both therapies (N=6) were excluded. The antiplatelet group presented more frequently with lobar hemorrhages (56% vs. 37%; p=0.022), while patients on anticoagulants showed increased rates of intraventricular hemorrhage co-presentation (62% vs. 46%; p=0.011) compared to controls. Despite univariate analyses showing a higher postoperative hematoma volume (3.9 vs. 2.9 milliliters; p=0.020) and lower evacuation percentage (88% vs. 92%; p=0.019) for the antiplatelet group, and longer procedures for patients on anticoagulants (2.3 vs. 1.7 hours; p=0.042) compared to control, multivariable analyses indicated that antiplatelets and anticoagulants had no significant impact on these technical outcomes. Longitudinally, antithrombotics were not associated with increased rebleeding, less frequent discharge to home, lower 30-day mortality, or worse, 6-month Modified Rankin Scale scores. CONCLUSIONS: Patients on chronic antiplatelets and anticoagulants exhibited characteristic intracerebral hemorrhage phenotypes without worse technical or long-term outcomes after minimally invasive intracerebral hemorrhage evacuation, suggesting the procedure's safety for these patients.

Vagal Nerve Stimulation: A Bibliometric Analysis of Current Research Trends.

BACKGROUND: Vagal nerve stimulation (VNS) has become established as an effective tool for the management of various neurologic disorders. Consequently, a growing number of VNS studies have been published over the past four decades. This study presents a bibliometric analysis investigating the current trends in VNS literature. MATERIALS AND METHODS: Using the Web of Science collection data base, a search was performed to identify literature that discussed applications of VNS from 2000 to 2021. Analysis and visualization of the included literature were completed with VOSviewer. RESULTS: A total of 2895 publications were identified. The number of articles published in this area has increased over the past two decades, with the most citations (7098) occurring in 2021 and the most publications (270) in 2020. The h-index, i-10, and i-100 were 97, 994, and 91, respectively, with 17.0 citations per publication on average. The highest-producing country and institution of VNS literature were the United States and the University of Texas, respectively. The most productive journal was Epilepsia. Epilepsy was the predominant focus of VNS research, with the keyword "epilepsy" having the greatest total link strength (749) in the keyword analysis. The keyword analysis also revealed two major avenues of VNS research: 1) the mechanisms by which VNS modulates neural circuitry, and 2) therapeutic applications of VNS in a variety of diseases beyond neurology. It also showed a significant prevalence of noninvasive VNS research. Although epilepsy research appears more linked to implanted VNS, headache and depression specialists were more closely associated with noninvasive VNS. CONCLUSION: VNS may serve as a promising intervention for rehabilitation beyond neurologic applications, with an expanding base of literature over the past two decades. Although epilepsy researchers have produced most current literature, other fields have begun to explore VNS as a potential treatment, likely owing to the rise of noninvasive forms of VNS.

Dysphagia after ischemic and hemorrhagic stroke: A propensity-matched 20-year analysis of the national inpatient sample.

OBJECTIVE: Dysphagia is a common symptom of acute ischemic stroke (AIS) and intracerebral hemorrhage (ICH), but little is known surrounding national trends of this post-stroke condition. Hence, this study aimed to identify the risk factors for dysphagia following AIS and ICH and evaluate in-hospital outcomes in these patients. METHODS: The 2000-2019 Nationwide Inpatient Sample was queried for patients admitted with AIS (ICD9 433, 43401, 43411, 43491, ICD-10 I63) and ICH (ICD9 431, 432.9, ICD-10 I61, I62.9). Univariate analysis with t-tests or chi-square performed as appropriate. A 1:1 nearest neighbor propensity score matched cohort was generated. Variables with standardized mean differences >0.1 were used in multivariable regression to generate adjusted odds ratios (AOR)/ß-coefficients for the presence of dysphagia on outcomes. RESULTS: Of 10,415,286 patients with AIS, 956,662 (9.2%) had in-hospital dysphagia. Total of 2,000,868 patients with ICH were identified; 203,511 (10.2%) had in-hospital dysphagia. Patients with dysphagia after AIS were less likely to experience in-hospital mortality (OR 0.61;95%CI: 0.60-0.63) or be discharged home (AOR 0.51;95%CI: 0.51-0.52), had increased length of stay (Beta-coefficient = 0.43 days; 95%CI: 0.36-0.50), and had increased hospital charges ($14411.96;95%CI: 13565.68-15257.44) (all p < 0.001). Patients with dysphagia after ICH were less likely to experience in-hospital mortality (AOR 0.39;95%CI: 0.37-0.4), less likely to be discharged home (AOR 0.59,95%CI:0.57-0.61), have longer hospital stay (Beta-coefficient = 1.99 days;95%CI: 1.78-2.21), and increased hospital charges ($28251.93; 95%CI: $25594.57-30909.28)(all p < 0.001). CONCLUSION: This is the first study to report on national trends in patients with dysphagia after AIS and ICH. These patients had longer hospital LOS, worse functional outcomes at discharge, and higher hospital costs.

Initial experience with minimally invasive endoscopic evacuation of intracerebral hemorrhage in the setting of radiographic herniation.

BACKGROUND: Spontaneous intracerebral hemorrhage (ICH) can rapidly result in cerebral herniation, leading to poor neurologic outcomes or mortality. To date, neither decompressive hemicraniectomy (DH) nor hematoma evacuation have been conclusively shown to improve outcomes for comatose ICH patients presenting with cerebral herniation, with these patients largely excluded from clinical trials. Here we present the outcomes of a series of patients presenting with ICH and radiographic herniation who underwent emergent minimally invasive (MIS) ICH evacuation. METHODS: We reviewed our prospectively collected registry of patients undergoing MIS ICH evacuation at a single institution from 01/01/2017 to 10/01/2021. We selected all consecutive patients with Glasgow coma scale (GCS) ≤ 8 and radiographic herniation for this case series. Clinical and radiographic variables were collected, including admission GCS score, preoperative and postoperative hematoma volumes, National Institute of Health stroke scale (NIHSS) scores, and modified Rankin scale (mRS) scores at last follow-up. RESULTS: Of 176 patients with spontaneous supratentorial ICH who underwent minimally invasive endoscopic evacuation during the study time period, a total of 9 patients presented with GCS ≤ 8 and evidence of radiographic herniation. Among these patients, the mean age was 62 ± 12 years, the median GCS at presentation was 5 [IQR 4-6], the mean preoperative hematoma volume was 94 ± 44 mL, the mean time from ictus to evacuation was 12 ± 5 h, and the mean postoperative hematoma volume was 11 ± 16 mL, for a median evacuation percentage of 97% [83-99]. Three patients (33%) died, four (44%) survived with mRS 5 and two (22%) with mRS 4. Patients had a median NIHSS improvement of 5 compared to their initial NIHSS. Age was very strongly correlate to improvements in NIHSS (r2 = 0.90). CONCLUSION: Data from this initial experience suggest emergent MIS hematoma evacuation in the setting of ICH with radiographic herniation is feasible and technically effective. Further randomized studies are required to determine if such an intervention offers overall benefits to patients and their families.

Stroke and COVID-19: The Value of Narrative Medicine.

Stroke and COVID-19 are both traumatic and life-altering experiences that are marked by uncertainty, fear, and medical intervention. The devastation that stroke and COVID-19 oppress on an individual and a population is well established, and these traumas are potently magnified in the troughs of the COVID-19 pandemic. Furthermore, stroke has been shown to be a potential complication of COVID-19 infection, and while there is global controversy regarding this finding, it is undeniable that there are patients across the world presenting with both conditions concurrently. Thus, the topic of isolated stroke and the co-occurrence of stroke and COVID-19 amidst the pandemic both warrant considerable investigation on both a basic science level and a humanistic level. This opinion article advocates for a narrative medicine approach to better explicate the intertwining of stroke and COVID-19. Interviewing patients who presented with both stroke and COVID-19 as well as patients who present with stroke during the pandemic will provide the opportunity to gather and juxtapose individual illness experiences, including encounters with the health care system, relationship with care teams and care takers, recovery, and insights into the future. Creating, analyzing, and comparing such an anthology of illness narratives of the 2 patient populations will offer a unique understanding into the experience of different, yet over-lapping, medical traumas in an unprecedented time. With this deeper appreciation of patient accounts, the health care system can better recognize how to provide for future patients who present specifically with stroke or stroke and COVID-19. However, more broadly, this study can also afford insight into how the health care system can better provide for and support patients who present with complex diagnoses in the context of a complex healthcare system, which most probably will operate under the effects of the pandemic for time to come as well as other, future complicating factors.

Gamified Neurorehabilitation Strategies for Post-stroke Motor Recovery: Challenges and Advantages.

PURPOSE OF REVIEW: Stroke is the leading cause of permanent motor disability in the United States (US), but there has been little progress in developing novel, effective strategies for treating post-stroke motor deficits. The past decade has seen the rapid development of many promising, gamified neurorehabilitation technologies; however, clinical adoption remains limited. The purpose of this review is to evaluate the recent literature surrounding the adoption and use of gamification in neurorehabilitation after stroke. RECENT FINDINGS: Gamification of neurorehabilitation protocols is both feasible and effective. Deployment strategies and scalability need to be addressed with more rigor. Relationship between engaged time on task and rehabilitation outcomes should be explored further as it may create benefits beyond repetitive movement. As gamification becomes a more common and feasible way of delivering exercise-based therapies, additional benefits of gamification are emerging. In spite of this, questions still exist about scalability and widespread clinical adoption.

Accuracy of artificial intelligence for the detection of intracranial hemorrhage and chronic cerebral microbleeds: a systematic review and pooled analysis.

BACKGROUND: Artificial intelligence (AI)-driven software has been developed and become commercially available within the past few years for the detection of intracranial hemorrhage (ICH) and chronic cerebral microbleeds (CMBs). However, there is currently no systematic review that summarizes all of these tools or provides pooled estimates of their performance. METHODS: In this PROSPERO-registered, PRISMA compliant systematic review, we sought to compile and review all MEDLINE and EMBASE published studies that have developed and/or tested AI algorithms for ICH detection on non-contrast CT scans (NCCTs) or MRI scans and CMBs detection on MRI scans. RESULTS: In total, 40 studies described AI algorithms for ICH detection in NCCTs/MRIs and 19 for CMBs detection in MRIs. The overall sensitivity, specificity, and accuracy were 92.06%, 93.54%, and 93.46%, respectively, for ICH detection and 91.6%, 93.9%, and 92.7% for CMBs detection. Some of the challenges encountered in the development of these algorithms include the laborious work of creating large, labeled and balanced datasets, the volumetric nature of the imaging examinations, the fine tuning of the algorithms, and the reduction in false positives. CONCLUSIONS: Numerous AI-driven software tools have been developed over the last decade. On average, they are characterized by high performance and expert-level accuracy for the diagnosis of ICH and CMBs. As a result, implementing these tools in clinical practice may improve workflow and act as a failsafe for the detection of such lesions. REGISTRATION-URL: https://www.crd.york.ac.uk/prospero/ Unique Identifier: CRD42021246848.

Portable stroke detection devices: a systematic scoping review of prehospital applications.

BACKGROUND: The worldwide burden of stroke remains high, with increasing time-to-treatment correlated with worse outcomes. Yet stroke subtype determination, most importantly between stroke/non-stroke and ischemic/hemorrhagic stroke, is not confirmed until hospital CT diagnosis, resulting in suboptimal prehospital triage and delayed treatment. In this study, we survey portable, non-invasive diagnostic technologies that could streamline triage by making this initial determination of stroke type, thereby reducing time-to-treatment. METHODS: Following PRISMA guidelines, we performed a scoping review of portable stroke diagnostic devices. The search was executed in PubMed and Scopus, and all studies testing technology for the detection of stroke or intracranial hemorrhage were eligible for inclusion. Extracted data included type of technology, location, feasibility, time to results, and diagnostic accuracy. RESULTS: After a screening of 296 studies, 16 papers were selected for inclusion. Studied devices utilized various types of diagnostic technology, including near-infrared spectroscopy (6), ultrasound (4), electroencephalography (4), microwave technology (1), and volumetric impedance spectroscopy (1). Three devices were tested prior to hospital arrival, 6 were tested in the emergency department, and 7 were tested in unspecified hospital settings. Median measurement time was 3 minutes (IQR: 3 minutes to 5.6 minutes). Several technologies showed high diagnostic accuracy in severe stroke and intracranial hematoma detection. CONCLUSION: Numerous emerging portable technologies have been reported to detect and stratify stroke to potentially improve prehospital triage. However, the majority of these current technologies are still in development and utilize a variety of accuracy metrics, making inter-technology comparisons difficult. Standardizing evaluation of diagnostic accuracy may be helpful in further optimizing portable stroke detection technology for clinical use.

Intraoperative imaging reveals spot sign with surgical correlate during early endoscopic ICH evacuation.

Intracerebral hemorrhage (ICH) is the most devastating form of stroke. Intraoperative imaging and management of intracavity bleeding during early endoscopic ICH evacuation may mitigate rebleeding, hematoma expansion, and neurological worsening. Here we document a case of intraoperative spot sign, detected in the angio suite using cone beam CT with contrast protocol, in a patient with spontaneous supratentorial ICH undergoing evacuation 13 hours after last known well. The spot sign was detected after endoscopic evaluation of the evacuated hematoma cavity demonstrated sufficient hemostasis, but before completion of the case and skin closure, prompting second-pass hematoma evacuation as well as identification and cauterization of the specific correlating bleeding vessel, resulting in near-complete evacuation of the hematoma. Spot sign detection on intraoperative cone beam CT followed by endoscopic ICH evacuation may provide an opportunity to specifically target and treat active bleeding and mitigate impending expansion and neurologic worsening, especially in high-risk patients, including those undergoing early ICH evacuation.

Time to Evacuation and Functional Outcome After Minimally Invasive Endoscopic Intracerebral Hemorrhage Evacuation.

BACKGROUND AND PURPOSE: We present a retrospective analysis of patients who underwent minimally invasive endoscopic intracerebral hemorrhage (ICH) evacuation to identify variables that were associated with long-term outcome. METHODS: Minimally invasive endoscopic ICH evacuation was performed on patients with supratentorial ICH who fit prespecified clinical inclusion and exclusion criteria. Demographic, clinical, and radiographic factors previously demonstrated to impact functional outcome in ICH were included in a univariate analysis to identify factors associated with favorable outcome (modified Rankin Scale score, 0-3) at 6 months. Factors associated with a favorable outcome in the univariate analysis (P≤0.20) were included in a multivariate logistic regression analysis with the same dependent variable. RESULTS: Ninety patients underwent MIS endoscopic ICH evacuation within 72 hours of ictus. In a multivariate analysis, factors associated with good long-term functional outcome included time to evacuation (per hour; OR, 0.95 [95% CI, 0.92-0.98], P=0.004), age (per decade, odds ratio [OR], 0.49 [95% CI, 0.28-0.77], P=0.005), presence of intraventricular hemorrhage (OR, 0.15 [95% CI, 0.04-0.47], P=0.002), and lobar location (OR, 18.5 [95% CI, 4.5-103], P=0.0005). Early evacuation was not associated with an increased risk of rebleeding. CONCLUSIONS: Young age, lack of intraventricular hemorrhage, lobar location, and time to evacuation were independently associated with good long-term functional outcome in patients undergoing minimally invasive endoscopic ICH evacuation. The OR for time to evacuation suggests that for each additional hour, there was a 5% reduction in the odds of achieving a favorable outcome.

Epidemiological Surveillance of the Impact of the COVID-19 Pandemic on Stroke Care Using Artificial Intelligence.

BACKGROUND AND PURPOSE: The degree to which the coronavirus disease 2019 (COVID-19) pandemic has affected systems of care, in particular, those for time-sensitive conditions such as stroke, remains poorly quantified. We sought to evaluate the impact of COVID-19 in the overall screening for acute stroke utilizing a commercial clinical artificial intelligence platform. METHODS: Data were derived from the Viz Platform, an artificial intelligence application designed to optimize the workflow of patients with acute stroke. Neuroimaging data on suspected patients with stroke across 97 hospitals in 20 US states were collected in real time and retrospectively analyzed with the number of patients undergoing imaging screening serving as a surrogate for the amount of stroke care. The main outcome measures were the number of computed tomography (CT) angiography, CT perfusion, large vessel occlusions (defined according to the automated software detection), and severe strokes on CT perfusion (defined as those with hypoperfusion volumes >70 mL) normalized as number of patients per day per hospital. Data from the prepandemic (November 4, 2019 to February 29, 2020) and pandemic (March 1 to May 10, 2020) periods were compared at national and state levels. Correlations were made between the inter-period changes in imaging screening, stroke hospitalizations, and thrombectomy procedures using state-specific sampling. RESULTS: A total of 23 223 patients were included. The incidence of large vessel occlusion on CT angiography and severe strokes on CT perfusion were 11.2% (n=2602) and 14.7% (n=1229/8328), respectively. There were significant declines in the overall number of CT angiographies (-22.8%; 1.39-1.07 patients/day per hospital, P<0.001) and CT perfusion (-26.1%; 0.50-0.37 patients/day per hospital, P<0.001) as well as in the incidence of large vessel occlusion (-17.1%; 0.15-0.13 patients/day per hospital, P<0.001) and severe strokes on CT perfusion (-16.7%; 0.12-0.10 patients/day per hospital, P<0.005). The sampled cohort showed similar declines in the rates of large vessel occlusions versus thrombectomy (18.8% versus 19.5%, P=0.9) and comprehensive stroke center hospitalizations (18.8% versus 11.0%, P=0.4). CONCLUSIONS: A significant decline in stroke imaging screening has occurred during the COVID-19 pandemic. This analysis underscores the broader application of artificial intelligence neuroimaging platforms for the real-time monitoring of stroke systems of care.

Real-World Experience with Artificial Intelligence-Based Triage in Transferred Large Vessel Occlusion Stroke Patients.

BACKGROUND AND PURPOSE: Randomized controlled trials have demonstrated the importance of time to endovascular therapy (EVT) in clinical outcomes in large vessel occlusion (LVO) acute ischemic stroke. Delays to treatment are particularly prevalent when patients require a transfer from hospitals without EVT capability onsite. A computer-aided triage system, Viz LVO, has the potential to streamline workflows. This platform includes an image viewer, a communication system, and an artificial intelligence (AI) algorithm that automatically identifies suspected LVO strokes on CTA imaging and rapidly triggers alerts. We hypothesize that the Viz application will decrease time-to-treatment, leading to improved clinical outcomes. METHODS: A retrospective analysis of a prospectively maintained database was assessed for patients who presented to a stroke center currently utilizing Viz LVO and underwent EVT following transfer for LVO stroke between July 2018 and March 2020. Time intervals and clinical outcomes were compared for 55 patients divided into pre- and post-Viz cohorts. RESULTS: The median initial door-to-neuroendovascular team (NT) notification time interval was significantly faster (25.0 min [IQR = 12.0] vs. 40.0 min [IQR = 61.0]; p = 0.01) with less variation (p < 0.05) following Viz LVO implementation. The median initial door-to-skin puncture time interval was 25 min shorter in the post-Viz cohort, although this was not statistically significant (p = 0.15). CONCLUSIONS: Preliminary results have shown that Viz LVO implementation is associated with earlier, more consistent NT notification times. This application can serve as an early warning system and a failsafe to ensure that no LVO is left behind.

National Trends in Utilization and Outcome of Endovascular Thrombectomy for Acute Ischemic Stroke in Elderly.

OBJECTIVE: Octogenarians were excluded and/or underrepresented in the major endovascular thrombectomy (EVT) randomized controlled trials, but continue to make up a growing proportion of stroke patients. To evaluate real-world trends in utilization and outcome of EVT in patients ≥80 years in a large nationally representative database. METHODS: Using the Nationwide Inpatient Sample (2014-2016), we identified patients admitted to United States hospitals with acute ischemic stroke (AIS) who also underwent EVT. The primary endpoint was good outcome (discharge to home/acute rehabilitation center). Poor outcome (discharge to skilled nursing facility or hospice and in-hospital mortality), intracerebral hemorrhage and in-hospital mortality were secondary outcome measures. RESULTS: In 376,956 patients with AIS, 6,230(1.54%) underwent EVT. 1,547(24.83%) were ≥80. The rate of EVT in AIS patients ≥80 more than doubled from 0.83%(n = 317) in 2014 to 1.83%(n = 695) in 2016. The rate of good outcome in patients ≥80 was 9%, significantly lower than younger patients (26%, p<0.001). In-hospital mortality was 19% in patients ≥80 compared to 13% in the younger cohort (p < 0.001). There was no difference in the rate of hemorrhagic transformation between octogenarians and younger patients (18.52% vs 17.01%, p=0.19). In patients ≥80 years of age, decreasing baseline comorbidity burden independently predicted good outcome (OR 0.258, 95% CI [0.674- 0.935]). CONCLUSIONS: A two-fold increase in the utilization of EVT in patients ≥80 years of age was seen from 2014 to 2016. While the comparative rate of good outcome is significantly lower in this age group, elderly patients with fewer comorbidities demonstrated better outcomes after EVT.

Mobile Interventional Stroke Team Model Improves Early Outcomes in Large Vessel Occlusion Stroke: The NYC MIST Trial.

BACKGROUND AND PURPOSE: Triage of patients with emergent large vessel occlusion stroke to primary stroke centers followed by transfer to comprehensive stroke centers leads to increased time to endovascular therapy. A Mobile Interventional Stroke Team (MIST) provides an alternative model by transferring a MIST to a Thrombectomy Capable Stroke Center (TSC) to perform endovascular therapy. Our aim is to determine whether the MIST model is more time-efficient and leads to improved clinical outcomes compared with standard drip-and-ship (DS) and mothership models. METHODS: This is a prospective observational cohort study with 3-month follow-up between June 2016 and December 2018 at a multicenter health system, consisting of one comprehensive stroke center, 4 TSCs, and several primary stroke centers. A total of 228 of 373 patients received endovascular therapy via 1 of 4 models: mothership with patient presentation to a comprehensive stroke center, DS with patient transfer from primary stroke center or TSC to comprehensive stroke center, MIST with patient presentation to TSC and MIST transfer, or a combination of DS with patient transfer from primary stroke center to TSC and MIST. The prespecified primary end point was initial door-to-recanalization time and secondary end points measured additional time intervals and clinical outcomes at discharge and 3 months. RESULTS: MIST had a faster mean initial door-to-recanalization time than DS by 83 minutes (P<0.01). MIST and mothership had similar median door-to-recanalization times of 192 minutes and 179 minutes, respectively (P=0.83). A greater proportion had a complete recovery (National Institutes of Health Stroke Scale of 0 or 1) at discharge in MIST compared with DS (37.9% versus 16.7%; P<0.01). MIST had 52.8% of patients with modified Rankin Scale of ≤2 at 3 months compared with 38.9% in DS (P=0.10). CONCLUSIONS: MIST led to significantly faster initial door-to-recanalization times compared with DS, which was comparable to mothership. This decrease in time has translated into improved short-term outcomes and a trend towards improved long-term outcomes. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT03048292.

COVID-19 and Decompressive Hemicraniectomy for Acute Ischemic Stroke.

BACKGROUND AND PURPOSE: Young patients with malignant cerebral edema have been shown to benefit from early decompressive hemicraniectomy. The impact of concomitant infection with coronavirus disease 2019 (COVID-19) and how this should weigh in on the decision for surgery is unclear. METHODS: We retrospectively reviewed all COVID-19-positive patients admitted to the neuroscience intensive care unit for malignant edema monitoring. Patients with >50% of middle cerebral artery involvement on computed tomography imaging were considered at risk for malignant edema. RESULTS: Seven patients were admitted for monitoring of whom 4 died. Cause of death was related to COVID-19 complications, and these were either seen both very early and several days into the intensive care unit course after the typical window of malignant cerebral swelling. Three cases underwent surgery, and 1 patient died postoperatively from cardiac failure. A good outcome was attained in the other 2 cases. CONCLUSIONS: COVID-19-positive patients with large hemispheric stroke can have a good outcome with decompressive hemicraniectomy. A positive test for COVID-19 should not be used in isolation to exclude patients from a potentially lifesaving procedure.

Systematic Review of Malpractice Litigation in the Diagnosis and Treatment of Acute Stroke.

Background and Purpose- The emergency management of stroke is complex and highly time-sensitive. Recent landmark trials demonstrating the strong benefit of thrombectomy have led to rapid change in stroke management. This article reviews a large number of medical malpractice lawsuits related to the emergency management of stroke to characterize factors involved in these lawsuits. Methods- Three large legal databases were used to search for jury verdicts and settlements in cases related to the acute care of stroke patients in the United States. Search terms included "stroke" and "medical malpractice." Cases were screened to include only cases in which the allegation involved negligence in the acute care of a patient suffering a stroke. Results- We found 246 medical malpractice cases related to the acute management of ischemic stroke and 26 related to intracranial hemorrhage. Seventy-one cases specifically alleged a failure to treat with tPA (tissue-type plasminogen activator) and 7 cases alleged a failure to treat, or to timely treat, with thrombectomy. Overall there were 151 cases (56%) which ended with no payout, 74 cases (27%) were settled out of court, and 47 cases (17%) went to court and resulted in a verdict for the plaintiff. The average payout in settlements was $1 802 693, and the average payout in plaintiff verdicts was $9 705 099. Conclusions- Malpractice litigation is a risk in acute stroke care and can lead to significant financial consequences. The majority of malpractice lawsuits related to the emergency management of stroke allege a failure to diagnose and failure to treat. Allegations of a failure to treat acute ischemic stroke with tPA were frequently found and are common in lawsuits. Allegations of a failure to treat a large vessel occlusion with thrombectomy were less frequently found. Given recent changes in practice guidelines and the demonstrated strong treatment effect of thrombectomy, it is likely that such litigation will increase in the coming years.

Obesity Paradox in Intracerebral Hemorrhage.

Background and Purpose- Although obesity is an established risk factor for cardiovascular disease and stroke, studies have shown evidence of an obesity paradox-a protective effect of obesity in patients who already have these disease states. Data on the obesity paradox in intracerebral hemorrhage is limited. Methods- Clinical data for adult intracerebral hemorrhage patients were extracted from the National Inpatient Sample between 2007 and 2014. Multivariable logistic regression analyzed the association of body habitus with in-hospital mortality, discharge disposition, length of stay, tracheostomy or gastrostomy placement, and ventriculoperitoneal shunt placement. Results- There were 99 212 patients who were eligible. Patients with both obesity (OR=0.69; 95% CI=0.62-0.76; P<0.001) and morbid obesity (OR=0.85; 95% CI=0.74-0.97; P=0.02) were associated with decreased odds of in-hospital mortality. Morbid obesity was significantly associated with increased odds of a tracheostomy or gastrostomy placement (OR=1.42; 1.20-1.69; P<0.001) and decreased odds of a routine discharge disposition (OR=0.84; 0.74-0.97; P=0.014). Conclusions- Obesity and morbid obesity appear to protect against mortality in intracerebral hemorrhage.