Comparison between moyamoya disease and moyamoya syndrome in Israel.

BACKGROUND AND AIMS: Moyamoya is a chronic brain vasculopathy involving the distal intracranial internal carotid artery (ICA) or proximal middle cerebral artery (MCA). Moyamoya patients can be divided into those with primary moyamoya disease (MMD) and those with moyamoya secondary to other known causes such as intracranial atherosclerosis (moymoya syndrome [MMS]). Our aim was to compare the characteristics of MMD patients to those of MMS patients in a sample of Israeli patients seen over the course of 20 years at a tertiary referral center. METHODS: Included patients were diagnosed with either MMD or MMS based on typical imaging findings and the presence or absence of known concomitant vascular risk factors or associated disorders and vascular disease. Patients with MMS were compared to those with MMD. Demographics, symptoms, signs, and radiological data were compared between the groups. Treatment options and long-term rates of recurrent stroke and functional outcome were also studied. RESULTS: Overall, 64 patients were included (25 MMD, 39 MMS). Patients with MMD were significantly younger (median IQR 20 (7-32) vs. 40 (19-52); p=0.035). Patients with MMS more often had vascular risk factors but there were no significant differences in clinical presentations or long-term disability rates between the groups and a similar proportion of patients underwent surgical interventions to restore hemispheric perfusion in both groups (48% vs. 44% MMS vs. MMD; p=0.7). Almost one in four patient had a recurrent stroke after the initial diagnosis in both groups. Most recurrences occurred in the pre-surgery period in the MMS group and in the post-surgery period in the MMD group. CONCLUSIONS: There were no statistically significant differences in clinical or radiological presentations between the MMS and MMD patients. The course is not benign with recurrent stroke occurring in as many as 25%. More data is needed in order to identify those at high risk for stroke occurrence and recurrence.

Effects of tumor type on outcomes in patients with large vessel occlusion stroke and cancer.

BACKGROUND: Large vessel occlusions (LVO) stroke is associated with cancer. Whether this association differs among patients with LVO that undergo endovascular thrombectomy (EVT) according to cancer type remains unknown. PATIENTS AND METHODS: Data from consecutive patients that underwent EVT for LVO at three academic centers were pulled and analyzed retrospectively. Patients with LVO and solid tumors were compared to those with hematological tumors. Associations of cancer type with 90-day functional outcome and mortality were calculated in multivariable analyses. RESULTS: Of the 154 patients with cancer and LVO that underwent EVT (mean age 74±11, 43% men, median NIHSS 15), 137 had solid tumors (89%) and 17 (11%) had hematologic tumors. Patients with solid cancer did not significantly differ from those with hematological malignancy in demographics, risk factor profile, stroke severity and subtype, and procedural variables. Outcome parameters including rates of favorable target recanalization and favorable outcome or mortality at discharge and 90 days post stroke were similar. Safety parameters including rates of symptomatic intracranial hemorrhage also did not differ between the groups. On regression analyses, controlling for various prognostic variables cancer type was not associated with mortality or favorable outcomes. CONCLUSIONS: Our study suggests that the safety and efficacy of EVT in patients with malignancy does not depend on cancer type. Patients with malignancy should be considered for EVT regardless of cancer type.

Covid-19 associated free hanging clots in acute symptomatic carotid stenosis.

BACKGROUND: Thrombotic complications including stroke were previously described following Covid-19. We aim to describe the clinical and radiological characteristics of Covid-19 related with acutely symptomatic carotid stenosis (aSCS). METHOD: All patients presenting with an aSCS were prospectively enrolled in an ongoing institutional database. Inclusion criteria for the Covid-19-aSCS group were a combination of both antigen test and a positive reverse-transcriptase (PCR) test for Covid-19 upon admission. Patients with additional potential etiologies for stroke including cardioembolism, carotid dissection or patients with stenosis of <50% on CTA were excluded. A cohort of non-Covid-19 related aSCS patients admitted to the same institution before the pandemic during 2019 served as controls. RESULTS: Compared to controls (n = 31), Covid-19-aSCS (n = 8), were younger (64.2 ± 10.7 vs 73.5 ± 10, p = 0.027), and less frequently had hypertension (50% vs 90%, p = 0.008) or hyperlipidemia (38% vs 77%, p = 0.029) before admission. Covid-19-aSCS patients had a higher admission NIHSS score (mean 9 ± 7 vs 3 ± 4, p = 0.004) and tended to present more often with stroke (88% vs 55%, p = 0.09) rather than a TIA. Covid-19-aSCS patients had higher rates of free-floating thrombus and clot burden on CTA (88% vs 6.5%, p = 0.002). Covid-19 patients also less often achieved excellent outcomes, with lower percentage of mRS score of 0 after 90-days (13% vs 58%, p = 0.022). CONCLUSION: Covid-19- aSCS may occur in a younger and healthier subpopulation. Covid-19- aSCS patients may have higher tendencies for developing complex clots and less often achieve excellent outcomes.

Predictors and Prognostic Implications of Hemorrhagic Transformation Following Cerebral Endovascular Thrombectomy in Acute Ischemic Stroke: A Multicenter Analysis.

PURPOSE: Hemorrhagic transformation (HT) following cerebral endovascular thrombectomy (EVT) for large vessel occlusion (LVO) in acute ischemic stroke is associated with poor outcome. Recent studies have shown that EVT can be efficacious in imaging-selected patients as late as 6-24 h from onset (late time window; LTW). We sought to determine predictors and prognostic implications of HT following EVT in LTW. METHODS: Consecutive patients undergoing EVT for LVO were recruited into a prospective multicenter database. HT was divided into petechial hemorrhagic-infarction and parenchymal hematoma (PH) type 1 or 2 defined as confluent hemorrhage covering < or > than 1/3 of the infarct volume, respectively. Multivariate analyses were performed to determine variables associated with HT subtypes. RESULTS: Among 611 patients included (mean age 70.5 ± 12.5 years; median NIHSS 16), 115 (18.8%) had HT and 33 of them (5.4%) had PH2. Independent PH2 predictors included failed recanalization (OR 7.0, 95% CI 2.3-21.6), longer time from symptom onset to admission (OR 1.002 per minute 95% CI 1.001-1.003) and hyperlipidemia (OR 3.12; 95%CI 1.12-8.7). HT was not associated with outcome. In contrast, PH2 patients had lower favorable outcome rates (14.3 vs 41.6%, p = 0.004) and higher mortality rates (39 vs 17%, p = 0.001). Patients who underwent EVT in the late versus early window had similar PH2 rates (4.5 vs 6.7%, p = 0.27). In multivariate models, PH2 tripled the odds of both 90-day poor outcome (OR 3.1, 95% CI 1.01-9.5) and 90-day mortality (OR 3.2, 95% CI 1.4-7.3). CONCLUSIONS: PH2 following EVT is associated with increased mortality and unfavorable outcome rates. Rates of PH2 are not different between LTW patients and those treated < 6 h from symptom onset.

Outcomes after reperfusion therapies in patients with ACA stroke: A multicenter cohort study from the EVATRISP collaboration.

BACKGROUND: Patients with stroke secondary to occlusions of the anterior cerebral artery (ACA) often have poor outcomes. The optimal acute therapeutic intervention for these patients remains unknown. METHODS: Patients with isolated ACA-stroke were identified from 10 centers participating in the EndoVascular treatment And ThRombolysis in Ischemic Stroke Patients (EVATRISP) prospective registry. Patients treated with endovascular thrombectomy (EVT) were compared to those treated with intravenous thrombolysis (IVT). Odds ratios with 95% confidence intervals (OR; 95%CI) were calculated using multivariate regression analysis. RESULTS: Included were 92 patients with ACA-stroke. Of the 92 ACA patients, 55 (60%) were treated with IVT only and 37 (40%) with EVT (±bridging IVT). ACA patients treated with EVT had more often wake-up stroke (24% vs. 6%, p = 0.044) and proximal ACA occlusions (43% vs. 24%, p = 0.047) and tended to have higher stroke severity on admission [NIHSS: 10.0 vs 7.0, p = 0.054). However, odds for favorable outcome, mortality or symptomatic intracranial hemorrhage did not differ significantly between both groups. Exploration of the effect of clot location inside the ACA showed that in patients with A1 or A2/A3 ACA occlusions the chances of favorable outcome were not influenced by treatment allocation to IVT or EVT. DISCUSSION: Treatment with either IVT or EVT could be safe with similar effect in patients with ACA-strokes and these effects may be independent of clot location within the occluded ACA.

Clopidogrel underactivity is a common in patients with acute symptomatic severe carotid stenosis.

BACKGROUND: Clopidogrel is commonly used for secondary stroke prevention in patients with large vessel stenosis. Reduced Clopidogrel high on treatment platelet reactivity (CR) can lead to Clopidogrel underactivity (CU) causing acute thrombosis. However, the prevalence of CU among patients with acute symptomatic carotid disease remains unknown. Therefore, we aimed to find the prevalence and identify the predictors for CU among patients with acutely symptomatic carotid stenosis. PATIENTS AND METHODS: Over the span of 14 months, CR was measured at the time of endovascular procedure in all patients undergoing angiography and stenting because of acute symptomatic carotid stenosis. Only patients treated per institutional protocol with a combination of Clopidogrel and Aspirin were included. CR was measured with VerifyNowP2Y12 reaction units (PRU) and CU was defined as PRU > 208. Patients with CU were compared to those without CU. RESULTS: Thirty-five patients were included (mean age 71.3 ± 10, 76% men) and twelve (34.3%, mean age 71.8 ± 8.4, 58% men) had CU at the time of endovascular intervention. On univariate analysis more severe carotid stenosis was seen in CU patients (92.6 ± 6.5% vs 81.6 ± 13.6%, p = 0.013) and percent stenosis was independently associated with CU on multivariate analysis (p = 0.023). CONCLUSIONS: CU is present in 1 of every 3 patients with acutely symptomatic carotid disease. The current results suggest that CR testing should become part of routine care in patients with acutely symptomatic carotid disease.

Influence of atrial fibrillation detection time on outcome after endovascular thrombectomy.

BACKGROUND: Cardiac emboli secondary to atrial fibrillation (AF) commonly cause large vessel occlusions (LVO) that require endovascular thrombectomy (EVT) to restore cerebral circulation. Whether the outcome of patients with AF diagnosed after the index stroke (newAF) differs from that of AF-patients in which AF was known before stroke (kAF) remains unknown. PATIENTS AND METHODS: Consecutive LVO patients treated with EVT were recruited and the data was analyzed retrospectively. We compared patients with newAF to those with kAF and those without AF. RESULTS: Among 230 patients included, 109 (47%) had AF (86 kAF, 23 newAF). Patients with kAF more often had prior strokes compared with those with newAF (20% vs. 4% p = 0.04) but other parameters did not differ between the groups. Both AF groups were significantly older, more often reached favorable recanalization and less often had favorable outcomes compared to those without AF. On multivariate analyses, timing of AF detection did not influence survival (Odds Ration [OR] 0.89 95% Confidence Interval [CI] 0.28-1.90), chances for favorable recanalization (OR 1.2 95% CI 0.44-3.26) or favorable outcome 1.32 (95% CI 0.57-3.05). CONCLUSIONS: Timing of AF diagnosis does not appear to influence outcome in patients with LVO that underwent EVT.

Atrial Fibrillation Treatment Adequacy and Outcome after Endovascular Thrombectomy.

BACKGROUND: Atrial fibrillation (AF) often leads to large vessel occlusions (LVO) which may necessitate endovascular thrombectomy (EVT). Whether the adequacy of treatment with oral anticoagulants (OAC) prior to LVO modifies outcomes remains unknown. PATIENTS AND METHODS: Consecutive EVT-treated LVO patients were recruited and the data was analyzed retrospectively. We combined patients with known AF that were untreated with OAC or inadequately treated with those with new-onset AF to form a group of undertreated-AF patients and compared them to adequately treated AF patients. RESULTS: Of the 230 patients included, 109 (47%) had AF (86 known AF, 23 new-onset AF). AF patients were significantly older and more often reached favorable recanalization but less often had favorable outcomes compared to those without AF. Most patients with known AF (76%) were inadequately treated at stroke onset. Patients with undertreated-AF more often received tPA prior to EVT (26% vs. 4% p=0.009), more often had favorable collaterals (65% vs. 33% p<0.001) and more often reached favorable outcomes (28% vs. 9%, p=0.047) compared to adequately treated AF patients. On multivariate analyses adequately treated AF did not impact survival (Odds Ration [OR] 0.89 95% Confidence Interval [CI] 0.23-3.43), chances for favorable recanalization (OR 0.57 95%CI 0.15-2.13) or favorable outcome (OR 5.95 95%CI 0.62-57.39). CONCLUSIONS: Treatment adequacy does not affect the rates of favorable functional outcome or survival in AF patients with LVO.

More than five stentriever passes: real benefit or futile recanalization?

BACKGROUND AND AIMS: Clot extraction is associated with favorable outcome in patients with large vessel occlusions (LVO) undergoing endovascular thrombectomy (EVT). However, whether revascularization becomes futile or harmful with an increasing number of passes remains unknown. METHODS: We performed a retrospective analysis of 271 consecutive patients with LVO who underwent stentriever-based EVT as the primary recanalization strategy. Primary outcomes including favorable recanalization, survival, and favorable functional outcomes were compared according to a dichotomized number of stentriever passes utilized with a cutoff of 4. RESULTS: In the entire cohort, 234 (86%) patients reached favorable recanalization and 46 (17%) patients had ≥ 5 passes (range 5-40). Patients that had ≤ 4 passes had significantly higher rates of favorable recanalization and favorable outcomes and a trend towards lower mortality rates compared with those that had ≥ 5 stentriever passes (92% vs. 61%; p < 0.001, 52% vs. 30%; p = 0.009 and 12% vs. 22%, p = 0.098). Among patients that received ≥ 5 stentriever passes, 30% reached favorable outcomes. Patients who achieved recanalization after ≥ 5 passes had higher rates of favorable outcome in comparison with those who did not (p = 0.009). Among patients that had ≥ 5 stentriever passes favorable recanalization (OR 97.3, 95%CI 2.8-3399.3) and admission NIHSS (OR 0.77, 95%CI 0.60-0.99) remained independent predictors of favorable outcome, whereas the number of passes did not. CONCLUSIONS: A substantial proportion of patients reach favorable outcomes even when ≥ 5 stentriever passes are performed. Treatment choices should be individualized based on personal preferences and expertise as well as on patient and clot-specific characteristics.

Intravenous thrombolysis for large vessel or distal occlusions presenting with mild stroke severity.

BACKGROUND AND PURPOSE: We investigated the effectiveness of intravenous thrombolysis (IVT) in acute ischaemic stroke (AIS) patients with large vessel or distal occlusions and mild neurological deficits, defined as National Institutes of Health Stroke Scale scores < 6 points. METHODS: The primary efficacy outcome was 3-month functional independence (FI) [modified Rankin Scale (mRS) scores 0-2] that was compared between patients with and without IVT treatment. Other efficacy outcomes of interest included 3-month favorable functional outcome (mRS scores 0-1) and mRS score distribution at discharge and at 3 months. The safety outcomes comprised all-cause 3-month mortality, symptomatic intracranial hemorrhage (ICH), asymptomatic ICH and severe systemic bleeding. RESULTS: We evaluated 336 AIS patients with large vessel or distal occlusions and mild stroke severity (mean age 63 ± 15 years, 45% women). Patients treated with IVT (n = 162) had higher FI (85.6% vs. 74.8%, P = 0.027) with lower mRS scores at hospital discharge (P = 0.034) compared with the remaining patients. No differences were detected in any of the safety outcomes including symptomatic ICH, asymptomatic ICH, severe systemic bleeding and 3-month mortality. IVT was associated with higher likelihood of 3-month FI [odds ratio (OR), 2.19; 95% confidence intervals (CI), 1.09-4.42], 3-month favorable functional outcome (OR, 1.99; 95% CI, 1.10-3.57), functional improvement at discharge [common OR (per 1-point decrease in mRS score), 2.94; 95% CI, 1.67-5.26)] and at 3 months (common OR, 1.72; 95% CI, 1.06-2.86) on multivariable logistic regression models adjusting for potential confounders, including mechanical thrombectomy. CONCLUSIONS: Intravenous thrombolysis is independently associated with higher odds of improved discharge and 3-month functional outcomes in AIS patients with large vessel or distal occlusions and mild stroke severity. IVT appears not to increase the risk of systemic or symptomatic intracranial bleeding.

Cerebellar hemorrhages in patients with cerebral amyloid angiopathy.

BACKGROUND: Cerebral amyloid angiopathy (CAA) typically involves the cerebral cortex but whether it affects the cerebellum remains uncertain. METHODS: Patients with intracerebral hemorrhage (ICH) who underwent magnetic resonance imaging were prospectively enrolled. Patients were diagnosed with CAA according to the Boston criteria and their hemorrhage types were categorized as macro-hematoma (MH) or microbleeds (MB). Patients with CAA and cerebellar involvement were compared with CAA patients without cerebellar involvement. RESULTS: Out of 614 patients with ICH, 85 (14%) had a post-ICH MRI. Of those, 41 (48%) were diagnosed with possible (n = 19), probable (n = 21) or definite (n = 1) CAA. Cerebellar involvement was seen in 14/41 (34%) patients with CAA. Most cerebellar lesions were of the MB type (35%) and most patients had several cerebellar MB typically involving the cerebellar cortex (85%). Patients with cerebellar involvement had larger numbers of lobar MB but clinical variables including age, gender, risk factor profile, mRS scores at 90 days or survival did not differ between those with and without cerebellar involvement. CONCLUSIONS: Cerebellar involvement may be common in CAA. Most patients have multiple superficial cerebellar MB. Clinical characteristics do not differ between CAA patients with or without cerebellar involvement. Patients presenting with cerebellar ICH should be screened for CAA with MRI.

First Documented Pathologies in Tenontosaurus tilletti with Comments on Infection in Non-Avian Dinosaurs.

In 2001, a nearly complete sub-adult Tenontosaurus tilletti was collected from the Antlers Formation (Aptian-Albian) of southeastern Oklahoma. Beyond its exceptional preservation, computed tomography (CT) and physical examination revealed this specimen has five pathological elements with four of the pathologies a result of trauma. Left pedal phalanx I-1 and left dorsal rib 10 are both fractured with extensive callus formation in the later stages of healing. Left dorsal rib 7 (L7) and right dorsal rib 10 (R10) exhibit impacted fractures compressed 26 mm and 24 mm, respectively. The fracture morphologies in L7 and R10 indicate this animal suffered a strong compressive force coincident with the long axis of the ribs. All three rib pathologies and the pathological left phalanx I-1 are consistent with injuries sustained in a fall. However, it is clear from the healing exhibited by these fractures that this individual survived the fall. In addition to traumatic fractures, left dorsal rib 10 and possibly left phalanx I-1 have a morphology consistent with post-traumatic infection in the form of osteomyelitis. The CT scans of left metacarpal IV revealed the presence of an abscess within the medullary cavity consistent with a subacute form of hematogenous osteomyelitis termed a Brodie abscess. This is only the second reported Brodie abscess in non-avian dinosaurs and the first documented occurrence in herbivorous dinosaurs. The presence of a Brodie abscess, known only in mammalian pathological literature, suggest mammalian descriptors for bone infection may be applicable to non-avian dinosaurs.

Smoking among female daily smokers in Surabaya, Indonesia.

OBJECTIVES: Nationally representative studies suggest 1-2% of Indonesian women (2.3 million) smoke various tobacco products daily; however, in recent years, there has been concern that the tobacco industry has successfully increased female smoking. Our objective was to describe current cigarette smoking behaviors, past quit attempts, and intention to quit of female daily smokers in Surabaya, Indonesia. STUDY DESIGN: Survey. METHODS: Female daily smokers (n = 112) in Surabaya, Indonesia, the country's second largest city, were recruited to participate in a survey during 2018. Convenience sampling was utilized in two malls. Potential participants were intercepted in or near designated smoking areas and invited to the nearby data collection site. Survey items from Global Adult Tobacco Survey and the International Tobacco Control Policy Evaluation Project were utilized. RESULTS: Participants self-reported smoking 13.8 cigarettes per day (7.3 white machine-rolled cigarettes per day, 4.2 kreteks per day, and 2.4 roll-your-own cigarettes per day). Over 75% smoked their first cigarette within 30 min of waking. Over 53% had a heaviness of smoking index score suggesting moderate or high addiction. Approximately half (51%) did not attempt to quit smoking in the previous 12 months, and 55% planned to quit beyond 6 months or not at all. CONCLUSIONS: Our sample smoked five to six more cigarettes per day than female daily smokers in previous national surveys. Relative to previous studies, our data suggest an unexpected preference for white machine-rolled cigarettes and that there could be, at a minimum, pockets of increased smoking and addiction among female daily smokers in Indonesia.

Clot length does not impact outcome following thrombectomy.

BACKGROUND AND AIMS: Clot length was associated with outcome after treatment with intravenous tissue plasminogen activator (tPA) in patients with stroke secondary to emergent large vessel occlusions (ELVO) but data regarding the influence of clot length on outcome after thrombectomy is lacking. PATIENTS AND METHODS: Prospectively accrued data on consecutive patients with ELVO treated with thrombectomy was analyzed. Data on demographics, risk factors, stroke severity, survival and occurrence of symptomatic intracranial hemorrhage (sICH) was collected. Procedural details including clot length measured on the pre-thrombectomy digital subtraction angiograms in multiple projections were collected. Functional outcome was determined with the modified Rankin Scale (mRS) 90 days post stroke and mRS ≤ 2 was considered as favorable outcome. RESULTS: Data was collected for 94 patients that fulfilled entry criteria. On univariate analysis clot length did not differ between patients with favorable or unfavorable outcomes. Clot length also did not influence the rates of sICH or mortality. On multivariate logistic regression age and stroke severity remained significant modifiers for favorable outcome. In a second regression model age, poor collaterals, the number of passes needed for recanalization and the magnitude of change in neurological deficits between presentation and discharge remained significant modifiers of outcomes. However, clot length had no effect on outcome in both models. CONCLUSIONS: In patients undergoing thrombectomy for ELVO, clot length has no effect on functional outcomes, mortality or sICH. Therefore, patients with ELVO should not be excluded from thrombectomy based on lot length.

Using the theory of normative social behavior to understand compliance with a smoke-free law in a middle-income country.

Smoke-free laws, which ban smoking in public venues, can be effective in protecting public health, but it has been difficult to achieve compliance with these laws in low- and middle-income countries. This study was conducted to understand the social norms around public smoking and learn how to improve compliance in Bogor, the first Indonesian city to pass a comprehensive smoke-free law. Eleven stratified focus groups were conducted (n = 89). Data were analyzed using the theory of normative social behavior, which posits that the influence of descriptive norms (perceptions about what other people do) on behavior is moderated by injunctive norms (perceptions about what one is expected to do), outcome expectations and group identity. The findings showed that participants perceived smoking in public to be common for men (descriptive norm). Public smoking is acceptable except in places with air conditioning and around children or pregnant women (injunctive norms). Men smoke without penalty of social or legal sanctions (outcome expectations) and may feel affiliation with other smokers (group identity). Together, these factors support public smoking and inhibit compliance with the smoke-free law. Theory-based communication and policy remedies are suggested that may bolster compliance with Bogor's smoke-free law given the current pro-smoking norms.

Multimodal reperfusion therapy for large hemispheric infarcts in octogenarians: is good outcome a realistic goal?

BACKGROUND AND PURPOSE: MMRT may be beneficial in a subset of patients with large hemispheric stroke who cannot be treated with systemic thrombolysis. Because most previous studies only included relatively young patients, the outcome of very old patients given MMRT remains unknown. MATERIALS AND METHODS: Consecutive patients with large hemispheric stroke treated with MMRT and admitted to intensive care were included. We compared neurologic and functional outcomes between patients younger and older than 80 years. RESULTS: We included 14 patients older than 80 years and compared them with 66 patients who were younger than 80. Cerebrovascular risk factor profile, admission NIHSS scores, stroke etiology and pathogenesis, and procedure-related variables did not differ between the groups except for a higher prevalence of smoking in younger patients. Excellent target vessel recanalization (Thrombolysis in Myocardial Infarction score of 3) and good outcome at 90 days (modified Rankin Score ≤ 2) were more common in younger patients (45% versus 14%, P = .047, and 41% versus 0%, P = .008, respectively). In contrast, mortality rates were higher in octogenarians (43% versus 17%, respectively). CONCLUSIONS: In this study, very old patients had higher chances of mortality and a very low probability of achieving functional independence even after MMRT. Further prospective studies are needed to examine the futility of MMRT in the very old.

Assessing the reach of nicotine replacement therapy as a preventive public health measure.

INTRODUCTION: Access to Nicotine Replacement Therapy (NRT) is a key public health intervention to reduce smoking. We assessed prevalence and correlates of use of NRT in Ontario, where NRT is available without prescription. METHODS: Participants were a representative sample of 2262 adult smokers in the Ontario Tobacco Survey cohort. Prospectively measured use of NRT over a 6-month period was reported in relation to smoking behaviour and history, attempts to quit, receipt of other supports for cessation supports and attitudes toward NRT. RESULTS: Overall, 11% of smokers used NRT over the six-month follow-up period. Prevalence was 25% among the 27% of smokers matching clinical guidelines that recommend NRT as a therapeutic option, and low among smokers not trying to quit. CONCLUSION: With increasing accessibility of NRT, further surveillance and research are warranted to determine the impact of the reach and benefits of NRT, considering both the general and targeted smoking populations.