Correlations Between Physician and Hospital Stroke Thrombectomy Volumes and Outcomes: A Nationwide Analysis.

Background and Purpose: Despite the Joint Commission's certification requirement of ≥15 stroke thrombectomy (ST) cases per center and proceduralist annually, the relationship between ST case volumes and outcomes is uncertain. We sought to determine whether a proceduralist or hospital volume threshold exists that is associated with better outcomes among Medicare beneficiaries. Methods: Retrospective cohort study using validated International Classification of Diseases, Tenth Revision, Clinical Modification codes to identify admissions with acute ischemic stroke and treatment with ST. We used de-identified, national 100% inpatient Medicare data sets from January 1, 2016, to December 31, 2017 for US individuals aged ≥65 years. We calculated total procedures by proceduralist and hospital. We performed adjusted logistic regression of total cases as a predictor of inpatient mortality, good outcome (defined by dichotomized discharge disposition of inpatient rehabilitation or better), and 30-day readmission. We adjusted for sex, age, Charlson Comorbidity Index, availability of neurocritical care, teaching hospital status, socioeconomic status, 2-year stroke volume, and urban versus rural hospital location. We dichotomized case numbers incrementally to determine a volume threshold for better outcomes. Results: Thirteen thousand three hundred thirty-five patients were treated with ST by 2754 proceduralists at 641 hospitals. For every 10 more proceduralist cases, patients had 4% lower adjusted odds of inpatient mortality (adjusted odds ratio, 0.96 [95% CI, 0.95­0.98], P<0.0001) and 3% greater adjusted odds of good outcome (adjusted odds ratio, 1.03 [95% CI, 1.02­1.04], P<0.0001). For every 10 more hospital cases, patients had 2% lower odds of inpatient mortality (adjusted odds ratio, 0.98 [95% CI, 0.98­0.99], P=0.0003) and 2% greater odds of good outcome (adjusted odds ratio, 1.02 [95% CI, 1.01­1.02], P<0.0001). With increasing volumes, there were higher odds of better outcomes. Conclusions: Nationally, higher proceduralist and hospital ST case volumes were associated with reduced inpatient mortality and better outcome. These data support volume requirements in guidelines for ST training and certification.

Mobile Interventional Stroke Teams Improve Outcomes in the Early Time Window for Large Vessel Occlusion Stroke.

BACKGROUND AND PURPOSE: Endovascular thrombectomy for large vessel occlusion stroke is a time-sensitive intervention. The use of a Mobile Interventional Stroke Team (MIST) traveling to Thrombectomy Capable Stroke Centers to perform endovascular thrombectomy has been shown to be significantly faster with improved discharge outcomes, as compared with the drip-and-ship (DS) model. The effect of the MIST model stratified by time of presentation has yet to be studied. We hypothesize that patients who present in the early window (last known well of ≤6 hours) will have better clinical outcomes in the MIST model. METHODS: The NYC MIST Trial and a prospectively collected stroke database were assessed for patients undergoing endovascular thrombectomy from January 2017 to February 2020. Patients presenting in early and late time windows were analyzed separately. The primary end point was the proportion with a good outcome (modified Rankin Scale score of 0-2) at 90 days. Secondary end points included discharge National Institutes of Health Stroke Scale and modified Rankin Scale. RESULTS: Among 561 cases, 226 patients fit inclusion criteria and were categorized into MIST and DS cohorts. Exclusion criteria included a baseline modified Rankin Scale score of >2, inpatient status, or fluctuating exams. In the early window, 54% (40/74) had a good 90-day outcome in the MIST model, as compared with 28% (24/86) in the DS model (P<0.01). In the late window, outcomes were similar (35% versus 41%; P=0.77). The median National Institutes of Health Stroke Scale at discharge was 5.0 and 12.0 in the early window (P<0.01) and 5.0 and 11.0 in the late window (P=0.11) in the MIST and DS models, respectively. The early window discharge modified Rankin Scale was significantly better in the MIST model (P<0.01) and similar in the late window (P=0.41). CONCLUSIONS: The MIST model in the early time window results in better 90-day outcomes compared with the DS model. This may be due to the MIST capturing high-risk fast progressors at an earlier time point. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03048292.

Acute Cerebrovascular Events With COVID-19 Infection.

BACKGROUND AND PURPOSE: Coronavirus disease 2019 (COVID-19) has been associated with an increased incidence of thrombotic events, including stroke. However, characteristics and outcomes of COVID-19 patients with stroke are not well known. METHODS: We conducted a retrospective observational study of risk factors, stroke characteristics, and short-term outcomes in a large health system in New York City. We included consecutively admitted patients with acute cerebrovascular events from March 1, 2020 through April 30, 2020. Data were stratified by COVID-19 status, and demographic variables, medical comorbidities, stroke characteristics, imaging results, and in-hospital outcomes were examined. Among COVID-19-positive patients, we also summarized laboratory test results. RESULTS: Of 277 patients with stroke, 105 (38.0%) were COVID-19-positive. Compared with COVID-19-negative patients, COVID-19-positive patients were more likely to have a cryptogenic (51.8% versus 22.3%, P<0.0001) stroke cause and were more likely to suffer ischemic stroke in the temporal (P=0.02), parietal (P=0.002), occipital (P=0.002), and cerebellar (P=0.028) regions. In COVID-19-positive patients, mean coagulation markers were slightly elevated (prothrombin time 15.4±3.6 seconds, partial thromboplastin time 38.6±24.5 seconds, and international normalized ratio 1.4±1.3). Outcomes were worse among COVID-19-positive patients, including longer length of stay (P<0.0001), greater percentage requiring intensive care unit care (P=0.017), and greater rate of neurological worsening during admission (P<0.0001); additionally, more COVID-19-positive patients suffered in-hospital death (33% versus 12.9%, P<0.0001). CONCLUSIONS: Baseline characteristics in patients with stroke were similar comparing those with and without COVID-19. However, COVID-19-positive patients were more likely to experience stroke in a lobar location, more commonly had a cryptogenic cause, and had worse outcomes.

MRI negative myelopathy post mild SARS-CoV-2 infection: vasculopathy or inflammatory myelitis?

Since the onset of the COVID-19 pandemic, there have been rare reports of spinal cord pathology diagnosed as inflammatory myelopathy and suspected spinal cord ischemia after SARS-CoV-2 infection. Herein, we report five cases of clinical myelopathy and myeloradiculopathy in the setting of post-COVID-19 disease, which were all radiographically negative. Unlike prior reports which typically characterized hospitalized patients with severe COVID-19 disease and critical illness, these patients typically had asymptomatic or mild-moderate COVID-19 disease and lacked radiologic evidence of structural spinal cord abnormality. This case series highlights that COVID-19 associated myelopathy is not rare, requires a high degree of clinical suspicion as imaging markers may be negative, and raises several possible pathophysiologic mechanisms.

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.

Sex Differences in Post-Stroke Depression in the Elderly.

OBJECTIVE: Post-stroke depression (PSD) occurs in approximately one-third of ischemic stroke patients. However, there is conflicting evidence on sex differences in PSD. We sought to assess sex differences in risk and time course of PSD in US ischemic stroke (IS) patients. We hypothesized that women are at greater risk of PSD than men, and that a greater proportion of women experience PSD in the acute post-stroke phase. MATERIALS AND METHODS: We conducted a retrospective cohort study of 100% de-identified data for US Medicare beneficiaries admitted for ischemic stroke from July 1, 2016 to December 31, 2017. We calculated Kaplan-Meier unadjusted cumulative risk of depression, stratified by sex, up to 1.5 years following index admission. We performed Cox regression to report the hazard ratio (HR) for diagnosis of depression up to 1.5 years post-stroke in females vs. males, adjusting for patient demographics, comorbidities, length of stay, and acute stroke interventions. RESULTS: In elderly stroke patients, females (n=90,474) were 20% more likely to develop PSD than males (n=84,427) in adjusted models. Cumulative risk of depression was consistently elevated for females throughout 1.5 years of follow-up (0.2055 [95% CI 0.2013-0.2097] vs. 0.1690 [95% CI 0.1639-0.1741] (log-rank p < 0.0001). HR for PSD in females vs. males remained significant in fully adjusted analysis at 1.20 (95% CI 1.17-1.23, p < 0.0001). CONCLUSIONS: Over 1.5 years of follow-up, female stroke patients had significantly greater hazard of developing PSD, highlighting the need for long-term depression screening in this population and further investigation of underlying reasons for sex differences.

Nationwide Analysis of Endovascular Thrombectomy Provider Specialization for Acute Stroke.

BACKGROUND AND PURPOSE: Determine the extent of cerebrovascular expertise among the specialties of proceduralists providing endovascular thrombectomy (ET) for emergent large vessel occlusion stroke in the modern era of acute stroke among Medicare beneficiaries Methods: Retrospective cohort study using validated International Classification of Diseases, Tenth Revision, Clinical Modification codes to identify admissions with acute ischemic stroke and treatment with ET. We identified proceduralist specialty by linking the National Provider Identifier provided by Medicare to the specialty listed in the National Provider Identifier database, grouping into radiology, neurology, neurosurgery, other surgical, and internal medicine. We calculated the number of proceduralists and hospitals who performed ET, ET team specialty composition by hospital, and number of proceduralists who performed ET at multiple hospitals. RESULTS: Forty-two percent (n=5612) of ET were performed by radiology-background proceduralists, with unclear knowledge of how many were cerebrovascular specialists. Neurosurgery- and neurology-background interventionalists performed fewer but substantial numbers of cases, accounting for 24% (n=3217) and 23% (n=3124) of total cases, respectively. ET teams included a neurology- or neurosurgery-background proceduralist at 65% (n=407) of hospitals that performed ET and included both in 26% (n=160) of teams. CONCLUSIONS: Almost two-thirds of ET teams nationwide include a neurology- or neurosurgery-background proceduralist and higher volume centers in urban areas were more likely to have neurology- or neurosurgery-background proceduralists with cerebrovascular expertise on their team. It is unclear how many radiology-background interventionalists are cerebrovascular specialists versus generalists. Significant work remains to be done to understand the impact of proceduralist specialty, training, and cerebrovascular expertise on ET outcomes.

Characteristics and Outcomes of Retinal Artery Occlusion: Nationally Representative Data.

Background and Purpose- There are few large studies examining comorbidities, outcomes, and acute interventions for patients with retinal artery occlusion (RAO). RAO shares pathophysiology with acute ischemic stroke (AIS); direct comparison may inform emergent treatment, evaluation, and secondary prevention. Methods- The National Readmissions Database contains data on ≈50% of US hospitalizations from 2013 to 2015. We used International Classification of Diseases, Ninth Revision, codes to identify and compare index RAO and AIS admissions, comorbidities, and interventions and Clinical Comorbidity Software codes to identify readmissions causes, using survey-weighted methods when possible. Cumulative risk of all-cause readmission after RAO ≤1 year was estimated by Kaplan-Meier analysis. Results- Among 4871 RAO and 1 239 963 AIS admissions, patients with RAO were less likely (P<0.0001) than patients with AIS to have diabetes mellitus (RAO, 24.3% versus AIS, 36.8%), congestive heart failure (9.1% versus 14.8%), atrial fibrillation (15.5% versus 25.2%), or hypertension (62.2% versus 67.6%) but more likely to have valvular disease (13.3% versus 10.5%) and tobacco usage (38.6% versus 32.9%). In RAO admissions, thrombolysis was administered in 2.9% (5.8% in central RAO subgroup, versus 8.0% of AIS), therapeutic anterior chamber paracentesis in 1.0%, thrombectomy in none; 1.4% received carotid endarterectomy during index admission, 1.6% within 30 days. Nearly 1 in 10 patients with RAO were readmitted within 30 days and were more than twice as likely as patients with AIS to be readmitted for dysrhythmia or endocarditis. Readmission for stroke after RAO was the highest within the first 150 days after index admission, and risk was higher in central RAO than in branch RAO. Conclusions- Patients with RAO had high prevalence of many stroke risk factors, particularly valvular disease and smoking, which can be addressed to minimize subsequent risk. Despite less baseline atrial fibrillation, RAO patients were more likely to be readmitted for atrial fibrillation/dysrhythmias. A variety of interventions was administered. AIS risk is the highest shortly after RAO, emphasizing the importance of urgent, thorough neurovascular evaluation.

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.

Emergent Large Vessel Occlusion Stroke During New York City's COVID-19 Outbreak: Clinical Characteristics and Paraclinical Findings.

BACKGROUND AND PURPOSE: The 2019 novel coronavirus outbreak and its associated disease (coronavirus disease 2019 [COVID-19]) have created a worldwide pandemic. Early data suggest higher rate of ischemic stroke in severe COVID-19 infection. We evaluated whether a relationship exists between emergent large vessel occlusion (ELVO) and the ongoing COVID-19 outbreak. METHODS: This is a retrospective, observational case series. Data were collected from all patients who presented with ELVO to the Mount Sinai Health System Hospitals across New York City during the peak 3 weeks of hospitalization and death from COVID-19. Patients' demographic, comorbid conditions, cardiovascular risk factors, COVID-19 disease status, and clinical presentation were extracted from the electronic medical record. Comparison was made between COVID-19 positive and negative cohorts. The incidence of ELVO stroke was compared with the pre-COVID period. RESULTS: Forty-five consecutive ELVO patients presented during the observation period. Fifty-three percent of patients tested positive for COVID-19. Total patients' mean (±SD) age was 66 (±17). Patients with COVID-19 were significantly younger than patients without COVID-19, 59±13 versus 74±17 (odds ratio [95% CI], 0.94 [0.81-0.98]; P=0.004). Seventy-five percent of patients with COVID-19 were male compared with 43% of patients without COVID-19 (odds ratio [95% CI], 3.99 [1.12-14.17]; P=0.032). Patients with COVID-19 were less likely to be White (8% versus 38% [odds ratio (95% CI), 0.15 (0.04-0.81); P=0.027]). In comparison to a similar time duration before the COVID-19 outbreak, a 2-fold increase in the total number of ELVO was observed (estimate: 0.78 [95% CI, 0.47-1.08], P≤0.0001). CONCLUSIONS: More than half of the ELVO stroke patients during the peak time of the New York City's COVID-19 outbreak were COVID-19 positive, and those patients with COVID-19 were younger, more likely to be male, and less likely to be White. Our findings also suggest an increase in the incidence of ELVO stroke during the peak of the COVID-19 outbreak.

Index Admission Characteristics and All-Cause Readmissions Analysis in Younger and Older Adults with Intracerebral Hemorrhage.

INTRODUCTION: Intracerebral hemorrhage (ICH) comprises 15-20% of all strokes with debilitating consequences. Data regarding characteristics and outcomes of primary ICH in the young are lacking, given its rarity, making comparisons between younger and older cohorts difficult to perform. Nationally representative administrative databases enable analysis of such rare events. OBJECTIVE: To determine the baseline characteristics, all-cause readmission rates, and reasons for primary ICH in younger and older adults using a nationally representative database. METHODS: A retrospective cohort analysis was performed using the Nationwide Readmissions Database 2013. Validated ICD-9-CM codes identified index ICH admissions, comorbidities, demographics, behavioral risk factors, procedures, and Elixhauser and Charlson Comorbidity indices. We compared "younger" (age ≤ 45 years) and "older" (age > 45) index ICH admissions by weighted 30-day all-cause readmission rates, primary diagnosis code for 30-day readmissions, most common comorbidities during the index hospitalization, and Kaplan-Meier cumulative risk of readmission up to 1 year. RESULTS: Older admissions had higher comorbidity scores and mortality, but both groups had similar total comorbidities. Younger admissions exhibited longer length of stay with more procedures performed. Vascular anomalies (aneurysm 7.2 vs. 4.6% and arteriovenous malformation 5.9 vs. 0.8%) and behavioral risk factors (smoking 26.5 vs. 23.0%, alcohol abuse 6.7 vs. 4.6%, and substance use 13.5 vs. 2.9%) were more prevalent in younger admissions, while older patients had more cardiovascular comorbidities. All-cause 30-day readmission rates (13.1 vs. 13.0%) and 1-year cumulative risk of readmission (log-rank p value 0.7209) were similar. Readmissions in the younger cohort were primarily for neurological conditions, and those in the older cohort were for systemic conditions. CONCLUSIONS: Adults <45 years with ICH had similar total comorbidities as older adults but more procedures, longer hospital stay, and more behavioral risk factors. Readmission rates were similar though reasons differed; younger patients were more for neurological reasons than for other systemic causes.

Interhospital Transfers for Endovascular Therapy for Acute Ischemic Stroke.

Background and Purpose- Multiple randomized clinical trials have demonstrated the superiority of endovascular therapy (ET) for large vessel occlusion acute ischemic stroke (AIS). Few centers can provide ET, and significant debate exists about the most efficient and effective ways to provide ET. We sought to assess real-world utilization of ET, the extent to which patients are transferred from one hospital to another for therapy and the implications of transfer status on outcomes. Methods- We used the 2015 to 2016 Healthcare Cost and Utilization Project Nationwide Readmissions Database, which contains nationwide data on nearly half of US admissions. We identified index AIS admissions, vascular risk factors, and treatment with intravenous thrombolysis and ET using International Classification of Disease, Ninth Revision, and International Classification of Disease, Tenth Revision Clinical Modification codes. Main predictors of outcome were treatment with ET and whether there was an interhospital transfer during the index AIS hospitalization. Among patients with AIS readmitted within 30 days, we examined 3 main outcomes: total charges, length of stay, and in-hospital mortality. Results- A total of 23 121 AIS admissions were treated with ET and 874 229 without. Over 5% of patients who received ET were transferred during the index admission compared with <2% of those not treated with ET. Length of stay and total charges were significantly higher in patients transferred (12.3 versus 9.6 days and $233 626 versus $182 881, respectively). More patients treated with ET who were not transferred to the index hospital were discharged home (25.3% versus 44.4%), and ≈25% of patients transferred for ET died during the hospitalization compared with 15.5% not transferred. Conclusions- The minority of all patients with AIS receive ET. The majority of patients who receive ET present directly to the center that performs the procedure, and those transferred for ET have higher length of stay, cost, and mortality that those not transferred.

Major Causes for Not Performing Endovascular Therapy Following Inter-Hospital Transfer in a Complex Urban Setting.

INTRODUCTION: Endovascular therapy (EVT) has emerged as the standard of care for emergent large vessel occlusion (ELVO) acute ischemic stroke. An increasing number of patients with suspected ELVO are being transferred to stroke centers with interventional capacity. Not all such inter-hospital transfers result in EVT. AIM: To identify the major causes for not performing EVT following transfer. METHODS: An analysis of 222 consecutive patients with suspected ELVO transferred for potential EVT between January 2015 and -December 2017 within a New York City health system was performed. About 36% (80/222) were deemed EVT ineligible and compared to an EVT cohort. RESULTS: Major causes for not performing EVT were established infarct (34%), no or recanalized ELVO (31%), and mild or clinically improved symptoms (21%). In the established infarct subgroup, 28% (7/27) arrived at a stroke center with interventional capacity within 5 h of last known well, compared to 61% (83/142) in the EVT cohort (p = 0.003). In the no or recanalized ELVO subgroup, 40% (10/25) received computed tomographic angiography at the primary stroke center (PSC), compared to 73% (104/142) in the EVT cohort (p = 0.001). Among patients treated with intravenous thrombolysis, 6% (6/104) improved from a NIHSS of ≥6 to <6 following transfer. CONCLUSIONS: Established infarct, no or recanalized ELVO, and mild or clinically improved symptoms were the major causes for not performing EVT for patients transferred for ELVO management. These may be addressed by decreasing stroke onset to treatment times and timely ELVO detection at the PSC and/or pre-hospital triage.

Estimation of Ischemic Core Volume Using Computed Tomographic Perfusion.

Background and Purpose- Estimation of infarction based on computed tomographic perfusion (CTP) has been challenging, mainly because of noise associated with CTP data. The Bayesian method is a robust probabilistic method that minimizes effects of oscillation, tracer delay, and noise during residue function estimation compared with other deconvolution methods. This study compares CTP-estimated ischemic core volume calculated by the Bayesian method and by the commonly used block-circulant singular value deconvolution technique. Methods- Patients were included if they had (1) anterior circulation ischemic stroke, (2) baseline CTP, (3) successful recanalization defined by thrombolysis in cerebral infarction ≥IIb, and (4) minimum infarction volume of >5 mL on follow-up magnetic resonance imaging (MRI). CTP data were processed with circulant singular value deconvolution and Bayesian methods. Two established CTP methods for estimation of ischemic core volume were applied: cerebral blood flow (CBF) method (relative CBF, <30% within the region of delay >2 seconds) and cerebral blood volume method (<2 mL per 100 g within the region of relative mean transit time >145%). Final infarct volume was determined on MRI (fluid-attenuated inversion recovery images). CTP and MRI-derived ischemic core volumes were compared by univariate and Bland-Altman analysis. Results- Among 35 patients included, the mean/median (mL) difference for CTP-estimated ischemic core volume against MRI was -4/-7 for Bayesian CBF ( P=0.770), 20/12 for Bayesian cerebral blood volume ( P=0.041), 21/10 for circulant singular value deconvolution CBF ( P=0.006), and 35/18 for circulant singular value deconvolution cerebral blood volume ( P<0.001). Among all methods, Bayesian CBF provided the narrowest limits of agreement (-28 to 19 mL) in comparison with MRI. Conclusions- Despite existing variabilities between CTP postprocessing methods, Bayesian postprocessing increases accuracy and limits variability in CTP estimation of ischemic core.

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.

Baseline Characteristics and Readmissions after Cerebral Venous Sinus Thrombosis in a Nationally Representative Database.

BACKGROUND: There are limited epidemiologic data on cerebral venous sinus thrombosis (CVST). We aim to summarize baseline characteristics and outcomes using a large nationally representative administrative database. METHODS: Using the 2013 Nationwide Readmissions Database, we used validated International Classification of Disease, Ninth Revision codes to identify baseline characteristics of patients admitted with CVST. We calculated readmission rates (per 100,000 index hospitalizations) for neurological complications. Multivariable Poisson regression yielded rate ratios (RR) of associations between index admission variables and all-cause readmission up to 1 year. RESULTS: Among 2,105 patients with index admission for CVST, mean age was 46.8 (SD 18.4); 65.2% were female, and 6.1% were pregnant. Hemorrhagic stroke (15.6%) was more common than ischemic stroke (10.7%), seizure occurred in 16.3, and 3.7% of patients died during index hospitalization. The 90-day readmission rate (per 100,000 index CVST hospitalizations) was the highest for CVST (1,447) and ischemic stroke (755). Diabetes (RR 1.10, 95% CI 1.002-1.22), cancer (1.23, 1.09-1.39), insurance status (0.92, 0.83-0.97 for Medicare/private insurance vs. others), and discharge home (RR 0.89, 95% CI 0.85-0.99) were associated with increased readmission rate. CONCLUSIONS: We provide baseline characteristics and readmission rates after CVST over a 1-year period. In-hospital mortality rate and association with pregnancy were lower than previously observed.

Mobile Interventional Stroke Teams Lead to Faster Treatment Times for Thrombectomy in Large Vessel Occlusion.

BACKGROUND AND PURPOSE: Endovascular recanalization treatment for acute ischemic stroke is a complex, time-sensitive intervention. Trip-and-treat is an interhospital service delivery model that has not previously been evaluated in the literature and consists of a shared mobile interventional stroke team that travels to primary stroke centers to provide on-site interventional capability. We compared treatment times between the trip-and-treat model and the traditional drip-and-ship model. METHODS: We performed a retrospective analysis on 86 consecutive eligible patients with acute ischemic stroke secondary to large vessel occlusion who received endovascular treatment at 4 hospitals in Manhattan. Patients were divided into 2 cohorts: trip-and-treat (n=39) and drip-and-ship (n=47). The primary outcome was initial door-to-puncture time, defined as the time between arrival at any hospital and arterial puncture. We also recorded and analyzed the times of last known well, IV-tPA (intravenous tissue-type plasminogen activator) administration, transfer, and reperfusion. RESULTS: Mean initial door-to-puncture time was 143 minutes for trip-and-treat and 222 minutes for drip-and-ship (P<0.0001). Although there was a trend in longer puncture-to-recanalization times for trip-and-treat (P=0.0887), initial door-to-recanalization was nonetheless 79 minutes faster for trip-and-treat (P<0.0001). There was a trend in improved admission-to-discharge change in National Institutes of Health Stroke Scale for trip-and-treat compared with drip-and-ship (P=0.0704). CONCLUSIONS: Compared with drip-and-ship, the trip-and-treat model demonstrated shorter treatment times for endovascular therapy in our series. The trip-and-treat model offers a valid alternative to current interhospital stroke transfers in urban environments.

More Time Is Taken to Administer Tissue Plasminogen Activator in Ischemic Stroke Patients with Earlier Presentations.

BACKGROUND: In ischemic stroke, administration of tissue plasminogen activator (tPA) within 4.5 hours from the time last known well (LKW) improves outcomes, with better outcomes seen with earlier administration. However, for patients presenting early, a perception of significant remaining time within this window may lead to delayed tPA administration. We hypothesized that cases with a shorter LKW-to-stroke team activation (code) time will have a longer "code-to-tPA" administration time. METHODS: In the Mount Sinai Hospital Stroke Registry (2009-2015), 122 patients received tPA. The patients were divided by "LKW-to-code" time into 3 groups: 0-59 minutes (n = 38), 60-119 minutes (n = 49), and 120 minutes or more (n = 35). The code-to-tPA time was compared among these groups, adjusting for age, sex, National Institutes of Health Stroke Scale (NIHSS) score, and race-ethnicity. RESULTS: The average code-to-tPA time was 80 minutes in the 0-59 minutes group, 67 minutes in the 60-119 minutes group, and 52 minutes in the 120 minutes or more group (analysis of variance P < .0001). There was an average 28-minute difference (P = .021) between the 0-59 and 120 minutes or more groups. CONCLUSION: There was a significant negative correlation between the LKW-to-code time and the code-to-tPA time that was independent of age, sex, NIHSS score, and race-ethnicity.

Prevalence of Depression Among Stroke Survivors: Racial-Ethnic Differences.

BACKGROUND AND PURPOSE: Although poststroke depression is common, racial-ethnic disparities in depression among stroke survivors remain underexplored. Thus, we investigated the relationship between race/ethnicity and depression in a multiracial-ethnic stroke cohort. METHODS: Baseline survey data of validated scales of depression and functional status, demographics, comorbidities, and socioeconomic status were used from a recurrent stroke prevention study among community-dwelling urban stroke/transient ischemic attack survivors. RESULTS: The cohort included 556 participants with a mean age of 64 years. The majorities were black (44%) or latino (42%) and female (60%), had their last stroke/transient ischemic attack nearly 2 years before study enrollment, and lived below the poverty level (58%). Nearly 1 in 2 latinos, 1 in 4 blacks, and 1 in 8 whites were depressed. Multivariate logistic regression showed that survivors who were younger, were female, had ≥3 comorbid conditions, were functionally disabled from stroke, lacked emotional-social support, and who took antidepressants before study entry had higher risk of depression. Time since last stroke/transient ischemic attack did not affect the chance of depression. After adjusting for all above risk factors, latinos had 3× the odds of depression (95% confidence interval: 1.18-6.35) than whites; blacks and whites had similar odds of depression. CONCLUSIONS: This study reveals that latino stroke survivors have a significantly higher prevalence of depression compared with their non-latino counterparts.