Epidemiology of Spontaneous Cervical Artery Dissection: Population-Based Study.

BACKGROUND: Cervical artery dissection (CeAD) represents up to 15% to 25% of ischemic strokes in people under the age of 50 years. Noninvasive vessel imaging is increasingly used in clinical practice, but the impact on the frequency of detection of CeAD is unknown. In 2006, the yearly incidence rate of CeAD was estimated at 2.6 per 100 000 person-years, but the current incidence is unknown. METHODS: In this population-based retrospective observational cohort study, we utilized the resources of the Rochester Epidemiology Project to ascertain all adult residents of Olmsted County, MN, diagnosed with internal carotid artery dissection and common carotid artery dissection or vertebral artery dissection from 2002 to 2020. Patients with only intracranial involvement or CeAD following major trauma were excluded. Age-adjusted sex-specific and age- and sex-adjusted incidence rates were estimated using the US White 2010 decennial census, with rates expressed per 100 000 person-years. We assessed longitudinal trends by dividing the data into 5-year time intervals, with the last being a 4-year interval. RESULTS: We identified 123 patients with a diagnosis of CeAD. There were 63 patients with internal carotid artery dissection, 54 with vertebral artery dissection, 2 with concurrent internal carotid artery dissection and vertebral artery dissection, and 4 with common carotid artery dissection. There were 63 (51.2%) female patients and 60 (48.8%) male patients. The average age at diagnosis was 50.2 years (SD, 15.1 [95% CI, 20.1-90.5] years). The incidence rate of spontaneous CeAD encompassing all locations was 4.69 per 100 000 person-years (2.43 for internal carotid artery dissection and 2.01 for vertebral artery dissection). The incidence rate increased from 2.30 per 100 000 person-years from 2002 to 2006 to 8.93 per 100 000 person-years from 2017 to 2020 (P<0.0001). The incidence rate for female patients rose from 0.81 per 100 000 person-years from 2002 to 2006 to 10.17 per 100 000 person-years from 2017 to 2020. CONCLUSIONS: The incidence rate of spontaneous CeAD increased nearly 4-fold over a 19-year period from 2002 to 2020. The incidence rate in women rose over 12-fold. The increase in incidence rates likely reflects the increased use of noninvasive vascular imaging.

Anticoagulation Versus Antiplatelets in Spontaneous Cervical Artery Dissection: A Systematic Review and Meta-Analysis.

BACKGROUND: It is uncertain whether antiplatelets or anticoagulants are more effective in preventing early recurrent stroke in patients with cervical artery dissection. Following the publication of the observational Antithrombotic for STOP-CAD (Stroke Prevention in Cervical Artery Dissection) study, which has more than doubled available data, we performed an updated systematic review and meta-analysis comparing antiplatelets versus anticoagulation in cervical artery dissection. METHODS: The systematic review was registered in PROSPERO (CRD42023468063). We searched 5 databases using a combination of keywords that encompass different antiplatelets and anticoagulants, as well as cervical artery dissection. We included relevant randomized trials and included observational studies of dissection unrelated to major trauma. Where studies were sufficiently similar, we performed meta-analyses for efficacy (ischemic stroke) and safety (major hemorrhage, symptomatic intracranial hemorrhage, and death) outcomes using relative risks. RESULTS: We identified 11 studies (2 randomized trials and 9 observational studies) that met the inclusion criteria. These included 5039 patients (30% [1512] treated with anticoagulation and 70% [3527]) treated with antiplatelets]. In meta-analysis, anticoagulation was associated with a lower ischemic stroke risk (relative risk, 0.63 [95% CI, 0.43 to 0.94]; P=0.02; I2=0%) but higher major bleeding risk (relative risk, 2.25 [95% CI, 1.07 to 4.72]; P=0.03, I2=0%). The risks of death and symptomatic intracranial hemorrhage were similar between the 2 treatments. Effect sizes were larger in randomized trials. There are insufficient data on the efficacy and safety of dual antiplatelet therapy or direct oral anticoagulants. CONCLUSIONS: In this study of patients with cervical artery dissection, anticoagulation was superior to antiplatelet therapy in reducing ischemic stroke but carried a higher major bleeding risk. This argues for an individualized therapeutic approach incorporating the net clinical benefit of ischemic stroke reduction and bleeding risks. Large randomized clinical trials are required to clarify optimal antithrombotic strategies for management of cervical artery dissection.

Risk Profile of Patients with Spontaneous Cervical Artery Dissection.

OBJECTIVE: Epidemiological data to characterize the individual risk profile of patients with spontaneous cervical artery dissection (sCeAD) are rather inconsistent. METHODS AND RESULTS: In the setting of the Italian Project on Stroke in Young Adults Cervical Artery Dissection (IPSYS CeAD), we compared the characteristics of 1,468 patients with sCeAD (mean age = 47.3 ± 11.3 years, men = 56.7%) prospectively recruited at 39 Italian centers with those of 2 control groups, composed of (1) patients whose ischemic stroke was caused by mechanisms other than dissection (non-CeAD IS) selected from the prospective IPSYS registry and Brescia Stroke Registry and (2) stroke-free individuals selected from the staff members of participating hospitals, matched 1:1:1 by sex, age, and race. Compared to stroke-free subjects, patients with sCeAD were more likely to be hypertensive (odds ratio [OR] = 1.65, 95% confidence interval [CI] = 1.37-1.98), to have personal history of migraine with aura (OR = 2.45, 95% CI = 1.74-3.34), without aura (OR = 2.67, 95% CI = 2.15-3.32), and family history of vascular disease in first-degree relatives (OR = 1.69, 95% CI = 1.39-2.05), and less likely to be diabetic (OR = 0.65, 95% CI = 0.47-0.91), hypercholesterolemic (OR = 0.75, 95% CI = 0.62-0.91), and obese (OR = 0.41, 95% CI = 0.31-0.54). Migraine without aura was also associated with sCeAD (OR = 1.81, 95% CI = 1.47-2.22) in comparison with patients with non-CeAD IS. In the subgroup of patients with migraine, patients with sCeAD had higher frequency of migraine attacks and were less likely to take anti-migraine preventive medications, especially beta-blockers, compared with the other groups. INTERPRETATION: The risk of sCeAD is influenced by migraine, especially migraine without aura, more than by other factors, increases with increasing frequency of attacks, and seems to be reduced by migraine preventive medications, namely beta-blockers. ANN NEUROL 2023;94:585-595.

Dissecting and fusiform aneurysms of the superior cerebellar artery: anatomy, clinical presentation, and treatment outcomes.

The management of superior cerebellar aneurysms is still controversial. Although several techniques are available, the deep localization of the lesion and the limited number of cases increase the complexity of decision-making for optimal treatment. Only a few cases of dissecting and fusiform aneurysms of the superior cerebellar artery (SCA) are described in the literature, many of which are without long follow-ups. The study aims to offer an exhaustive retrospective analysis of patients affected by SCA fusiform and dissecting aneurysms treated at our institution from 2008 to 2023, highlighting outcomes and complications. Moreover, a comprehensive narrative review was performed. A total of seven patients were treated at our institution. After a title and abstract screen, fifty-five papers met the criteria for inclusion in the review. In our case series, conservative treatment was proposed as the first therapeutic option in four cases (57.1%), while endovascular treatment (EVT) was in three cases (42.9%). A good recovery was observed in 66% of patients presenting with subarachnoid hemorrhage (SAH), while every patient without SAH achieved a good clinical outcome. A poor outcome was observed only in one patient with a dissecting aneurysm causing SAH, who also suffered a pontine infarction. In the literature review, conservative treatment was proposed as a first therapeutic option in eleven cases (16.6%), open microsurgical techniques in 19 patients (28.8%), and EVT in 31 patients (46.9%). Fatal outcome was documented in five patients (7.5%), all characterized by the rupture of the vascular lesion, while 6.1% of cases had non-fatal poor outcomes.

Necessary to continue imaging spontaneous cervical artery dissecting pseudoaneurysms after one year?

BACKGROUND AND PURPOSE: The value of long-term serial imaging of dissecting pseudoaneurysm (dPSA) is poorly characterized. This study investigated the long-term radiographic evolution of dPSA. METHODS: We performed a query in our institutional craniocervical artery dissection registry to identify cases with spontaneous dPSA who had at least one year of follow-up with serial angiographic imaging. We performed Wilcoxon rank-sum pairwise comparison test to determine if there was a significant change in the aneurysm size over time. RESULTS: This observational cohort study included 76 patients (46 females; 64 dPSA in the internal carotid artery [ICA] and 12 in the vertebral artery [VA]) with a median age of 49.5 years (range 24-77). The initial median dPSA size was 8 mm (interquantile range(iqr) = 5.88-11mm), and the final median dPSA size was 7 mm (iqr = 4-11 mm). Most patients had either no change or reduction in dPSA size in the serial follow-up, with no significant change over time. All the patients had favorable outcomes at the last follow-up, and most patients were symptom-free from dPSA (92 %). Two patients (2.6%) experienced recurrent ischemic strokes in the same territory as the initial ischemic stroke without any change in dPSA size. CONCLUSION: Further serial scans for dPSA after one year may be deferred in the absence of interim clinical symptoms as most dPSA either remains stable or decreases in size. Recurrent stroke, although a rare event, was not associated with an increase in dPSA size.

Supervised, Self-Administered Tablet-Based Cognitive Assessment in Neurodegenerative Disorders and Stroke.

INTRODUCTION: As the population ages, the prevalence of cognitive impairment is expanding. Given the recent pandemic, there is a need for remote testing modalities to assess cognitive deficits in individuals with neurological disorders. Self-administered, remote, tablet-based cognitive assessments would be clinically valuable if they can detect and classify cognitive deficits as effectively as traditional in-person neuropsychological testing. METHODS: We tested whether the Miro application, a tablet-based neurocognitive platform, measured the same cognitive domains as traditional pencil-and-paper neuropsychological tests. Seventy-nine patients were recruited and then randomized to either undergo pencil-and-paper or tablet testing first. Twenty-nine age-matched healthy controls completed the tablet-based assessments. We identified Pearson correlations between Miro tablet-based modules and corresponding neuropsychological tests in patients and compared scores of patients with neurological disorders with those of healthy controls using t tests. RESULTS: Statistically significant Pearson correlations between the neuropsychological tests and their tablet equivalents were found for all domains with moderate (r > 0.3) or strong (r > 0.7) correlations in 16 of 17 tests (p < 0.05). All tablet-based subtests differentiated healthy controls from neurologically impaired patients by t tests except for the spatial span forward and finger tapping modules. Participants reported enjoyment of the tablet-based testing, denied that it provoked anxiety, and noted no preference between modalities. CONCLUSIONS: This tablet-based application was found to be widely acceptable to participants. This study supports the validity of these tablet-based assessments in the differentiation of healthy controls from patients with neurocognitive deficits in a variety of cognitive domains and across multiple neurological disease etiologies.

Supporting Post-Stroke Language and Cognition with Pharmacotherapy: Tools for Each Phase of Care.

PURPOSE OF REVIEW: There is enormous enthusiasm for the possibility of pharmacotherapies to treat language deficits that can arise after stroke. Speech language therapy remains the most frequently utilized and most strongly evidenced treatment, but the numerous barriers to patients receiving the therapy necessary to recover have motivated the creation of a relatively modest, yet highly cited, body of evidence to support the use of pharmacotherapy to treat post-stroke aphasia directly or to augment traditional post-stroke aphasia treatment. In this review, we survey the use of pharmacotherapy to preserve and support language and cognition in the context of stroke across phases of care, discuss key ongoing clinical trials, and identify targets that may become emerging interventions in the future. RECENT FINDINGS: Recent trials have shifted focus from short periods of drug therapy supporting therapy in the chronic phase to longer terms approaching pharmacological maintenance beginning more acutely. Recent innovations in hyperacute stroke care, such as tenecteplase, and acute initiation of neuroprotective agents and serotonin reuptake inhibitors are important areas of ongoing research that complement the ongoing search for effective adjuvants to later therapy. Currently there are no drugs approved in the United States for the treatment of aphasia. Nevertheless, pharmacological intervention may provide a benefit to all phases of stroke care.

Neuromodulation for Post-Stroke Motor Recovery: a Narrative Review of Invasive and Non­Invasive Tools.

PURPOSE OF REVIEW: Stroke remains a leading disabling condition, and many survivors have permanent disability despite acute stroke treatment and subsequent standard-of-care rehabilitation therapies. Adjunctive neuromodulation is an emerging frontier in the field of stroke recovery. In this narrative review, we aim to highlight and summarize various neuromodulation techniques currently being investigated to enhance recovery and reduce impairment in patients with stroke. RECENT FINDINGS: For motor recovery, repetitive transcranial magnetic simulation (rTMS) and direct current stimulation (tDCS) have shown promising results in many smaller-scale trials. Still, their efficacy has yet to be proven in large-scale pivotal trials. A promising large-scale study investigating higher dose tDCS combined with constraint movement therapy to enhance motor recovery is currently underway. MRI-guided tDCS studies in subacute and chronic post-stroke aphasia showed promising benefits for picture-naming recovery. rTMS, particularly inhibitory stimulation over the contralesional homolog, could represent a pathway forward in post-stroke motor recovery in the setting of a well-designed and adequately powered clinical trial. Recently evidenced-based guideline actually supported Level A (definite efficacy) for the use of low-frequency rTMS of the primary motor cortex for hand motor recovery in the post-acute stage of stroke based on the meta-analysis result. Adjunctive vagal nerve stimulation has recently received FDA approval to enhance upper limb motor recovery in chronic ischemic stroke with moderate impairment, and progress has been made to implement it in real-world practice. Despite a few small and large-scale studies in epidural stimulation (EDS), further research on the utilization of EDS in post-stroke recovery is needed. Deep brain stimulation or stent-based neuromodulation has yet to be further tested regarding safety and efficacy. Adjunctive neuromodulation to rehabilitation therapy is a promising avenue for promoting post-stroke recovery and decreasing the overall burden of disability. The pipeline for neuromodulation technology remains strong as they span from the preclinical stage to the post-market stage. We are optimistic to see that more neuromodulation tools will be available to stroke survivors in the not-to-distant future.

Fusiform aneurysms of anterior cerebral artery: center experience and systematic literature review.

Fusiform aneurysms of the anterior cerebral artery (ACA) are uncommon, and the natural history of this entity is poorly characterized. Along with our center experience, we conducted a systematic literature review to help shed light on the clinical course of ACA fusiform aneurysms. We queried our institutional database to identify cases with fusiform aneurysms of ACA. In addition, following the PRISMA algorithm, we identified all reported cases published in the English literature from the inception of PubMed until December 2022. We categorized clinical presentations into three categories: (i) traumatic/iatrogenic, (ii) spontaneous symptomatic ruptured/unruptured, and (iii) spontaneous asymptomatic aneurysms. We utilized descriptive statistics. We identified seven cases from our center along with 235 patients from published literature. Blunt trauma was responsible for the development of 19 aneurysms. Sixty-three percent of these aneurysms tend to rupture within 2 weeks from the initial trauma, and despite treatment, only 74% of these patients had good clinical outcomes. Spontaneous symptomatic presentation occurred in 207 patients and was often associated with previous/concomitant ACA dissection. Subarachnoid hemorrhage from ruptured aneurysms was the most common presentation. Spontaneous symptomatic fusiform aneurysm is rapidly evolving lesions, and treatment is necessary. Three of our own cases were treated with an endovascular flow diverter (pipeline) stenting with good outcomes. Spontaneous asymptomatic aneurysms were reported in nine patients. These lesions are often associated with other vascular abnormalities. Treatment included surgical clipping with good clinical outcomes. Instead, four patients from our center database were managed conservatively with equally good outcomes. Our study demonstrates good clinical outcomes when fusiform aneurysms of ACA, especially when symptomatic, are treated promptly with either reconstructive or deconstructive therapies.

Safety of intravenous thrombolysis for ischemic stroke in patients with hematologic malignancies: A single institution experience.

BACKGROUND: Data on safety of thrombolysis for acute ischemic stroke (AIS) in patients with hematologic malignancy is not well established. We report our single institution experience with thrombolysis in this patient population. METHODS: We identified patients with pathology-confirmed hematologic malignancy from 2000-2022. Primary exposure was presence of AIS and receipt of intravenous (IV) thrombolysis. Primary outcome was safety of IV thrombolysis in this patient population. Safety was measured through imaging review for hemorrhagic transformation, post-stroke mortality, and modified Rankin Scale (mRS) at 90 days. RESULTS: Among 45,894 patients with hematologic malignancy, 1,099 (2.4%) were identified as having a suspected AIS. Twenty (1.8%) received IV tissue plasminogen activator (tPA) for AIS, three underwent endovascular intervention, and 17 had AIS confirmed on MRI. Two patients with confirmed AIS experienced hemorrhagic transformation, one of which was symptomatic. Most patients (n=10, 59%) were functionally independent (mRS 0-2) at 90 days post-stroke, including all patients with active hematologic malignancy at the time of stroke (n=3). Four patients died within 90 days of AIS. None of these deaths were patients with active hematologic malignancy at the time of stroke. CONCLUSIONS: Without other contraindications, IV alteplase should be considered for management of AIS in patients with hematologic malignancy. The safety profile of tPA administration in this patient population may be similar to the general population, whether underlying hematologic malignancy is active or in remission.

Natural history and management of posterior cerebral artery aneurysms: a systematic review and meta-analysis of individual patient data.

We conducted a comprehensive review and meta-analysis to investigate clinical, radiographic characteristics, and treatment outcomes of posterior cerebral artery aneurysms (PCAA). We systematically reviewed English-language articles investigating available treatments (parent artery occlusion (PAO), microsurgery, reconstructive endovascular (rEVT), and conservative treatments) for PCAA and analyzed the based on aneurysm morphology and rupture status. Six-hundred-eighty-five patients with 698 PCAA were identified from 59 studies. Overall, 371 (54.2%) aneurysms were ruptured, 325 (49%) were saccular, and 342 (51%) were non-saccular aneurysms. The mean age of the saccular was lower (40 years) than non-saccular aneurysm group (50 years) (P < .05). In ruptured PCAA, favorable clinical outcomes were comparable between the treatment groups except for patients treated conservatively, which had lower rates of favorable clinical outcomes (35.6%) and higher mortality (55.7%) (P < .0001). Ruptured aneurysms treated with rEVT (22.6%) had the highest recanalization rates compared to PAO (9.2%, P = 0.0001) and microsurgery (3.8%, P = 0.005). In unruptured PCAA, clinical outcomes were similar; higher complication rates were noted in microsurgery (40.4%, P = 0.026) and PAO (21.5%, P = 0.015) compared to rEVT (13.2%), which had higher recanalization rates (15.6%, P < .0001). The rates of subsequent stroke following PAO were 21.8% for unruptured and 32.3% for ruptured PCAA (P = 0.078). Ruptured PCAA portend worse prognosis and typically require an intervention to achieve better outcome whereas the benefit of an intervention in unruptured PCAA is much less clear. rEVT is promising for PCAA management with a good clinical and safety profile but more recurrence compared to PAO and microsurgery.

Trends in admissions for intracranial dissections in the United States.

INTRODUCTION: Intracranial artery dissection (IAD) is rarer than cervical artery dissections (CeAD), and information is based on limited series with small cohorts. There are only several small-scale studies attempting to characterize the natural history of the disease. Herein, we analyze the prevalence of IADs in hospitalized patients using a national database. METHODS: The National Inpatient Sample was queried from 2016-2019 for patients with a diagnosis of unruptured intracranial dissection (uIAD) using ICD-10-CM codes (I67.0). Moreover, patients with acute ischemic stroke (AIS) and CeAD were extracted to compare its prevalence among patients with concomitant AIS (+/-dissections). The Cochrane-Armitage test was conducted to assess trends in the prevalence of uIADs among those with concomitant AIS or among all craniocervical dissections. RESULTS: There were 725 hospitalizations involving uIAD, while there were 62,220 involving CeADs. uIADs represented 5.1 per million hospitalizations across 2016-2019. The average age of presentation was 56.9 years (SE: 1.62), while it was 54.4 (SE: 0.17) for CeADs (p = 0.13). Females were represented among 44.8% (n = 325) of uIADs, a similar proportion compared to CeADs (44.3%%, n = 27,530; p = 0.89). Compared to CeADs, AIS and motor deficits were more common in uIAD (71.72% vs. 47.0%; p < 0.001). There were 18.6 uIAD with concomitant AIS per 100,000 with AIS. uIADs represented 1.75% of all dissections with concomitant AIS (n = 520/29,750). There was no trend in the average age of presentation for uIADs. Proportion of females among those with uIADs increased from 36.8% in 2016 to 59.5% in 2019 (trend: +9.46% per year; 95% CI: 3.13 to 15.8; p = 0.004). There was no trend in the proportion of races among those with uIADs. CONCLUSION: The prevalence of uIADs among hospitalized patients is very low, and only 1.75% of craniocervical dissection-related AIS is due to uIAD. Compared to CeADs, patients were more likely to be male, and uIAD more commonly led to acute ischemic stroke and motor deficits. The trend in age remained stable across the four years analyzed, while the proportion of females increased. There was no trend in the proportion of races among uIADs, however.

Right Hemispheric Homologous Language Pathways Negatively Predicts Poststroke Naming Recovery.

Background and Purpose- Stroke is the leading cause of disability in United States, and aphasia is a common sequela after a left hemisphere stroke. Functional imaging and brain stimulation studies show that right hemisphere structures are detrimental to aphasia recovery but evidence from diffusion tensor imaging is lacking. We investigated the role of homologous language pathways in naming recovery after left hemispheric stroke. Methods- Patients with aphasia after a left hemispheric stroke underwent naming assessment using the Boston Naming Test and diffusion tensor imaging at the acute and chronic time points. We analyzed diffusion tensor imaging of right arcuate fasciculus and frontal aslant tracts. We used Wilcoxon rank-sum test to evaluate structural lateralization patterns and partial Spearman correlation/multivariate generalized linear model to determine the role of right arcuate fasciculus and frontal aslant tracts in naming recovery after controlling for confounders. Results were corrected for multiple comparisons. Results- On average, the structural integrity of left language pathways deteriorated more than their right homologs, such that there was rightward lateralization in the chronic stage. Regression/correlation analyses showed that greater preservation of tract integrity of right arcuate fasciculus was associated with poorer naming recovery. Conclusions- Our study provides preliminary evidence that preservation of right homologs of language pathways is associated with poor recovery of naming after a left hemispheric stroke, consistent with previous evidence that maintaining greater reliance on left hemisphere structures is associated with better language recovery.

The role of residents in medical students' neurology education: current status and future perspectives.

BACKGROUND: Neurophobia, a well-described fear of neurology, affects medical students worldwide and may be one of the factors contributing to a shortage of neurologists in the United States. Residents spend a considerable amount of time with medical students; therefore, we sought to understand better the impact neurology residents have on medical students during their neurology clerkship and their subsequent interest in neurology. We aimed to identify and implement strategies to decrease neurophobia and increase the number of students pursuing neurology as a career. METHODS: Third-year medical students (n = 234) of UTHealth's McGovern Medical School rotating through their neurology core clerkship completed two surveys regarding their rotation experiences. Surveys were completed anonymously before and after the clerkship to measure their interest and confidence in neurology and the impact of their interactions with the neurology residents during the clerkship. In parallel, residents participated in a teaching workshop focused on small group teaching to improve their teaching effectiveness. Non-parametrical comparison and ordinal regression analyses were utilized for data analyses. RESULTS: Medical students reported a statistically significant increase in their confidence in managing neurological conditions and interest in pursuing a neurology residency after their clerkship. There was a significant association between the medical students' overall rotation experience and the residents' teaching effectiveness. The overall clerkship experience correlated with the medical students' interest and confidence in neurology. There was a trend towards an increase in residents' teaching effectiveness and students' rotation experience after a resident teaching workshop. Additionally, of note, students who rotated on both and outpatient and inpatient sites during their clerkship reported an increased interest in neurology. CONCLUSION: Our study supports that resident-led teaching efforts are important in improving medical students' neurologic education and their interest in neurology. Our data also supports that the interest in neurology increased for medical students after their neurology clerkship. We examined future strategies to implement "near-peer" teaching activities to enhance the medical students' neurologic educational experience. These strategies could potentially mitigate neurophobia and ultimately lead to a much-needed increase in future neurologists.

The role of microstructural integrity of major language pathways in narrative speech in the first year after stroke.

BACKGROUND AND PURPOSE: Left hemisphere stroke often results in a variety of language deficits due to varying patterns of damage to language networks. The Cookie Theft picture description task, a classic, quick bedside assessment, has been shown to quantify narrative speech reliably. In this study, we utilized diffusion tensor imaging (DTI) to assess language network white matter tract correlates of lexical-semantic and syntactic impairments longitudinally. METHODS: Twenty-eight patients with mild to severe language impairments after left hemispheric lobar and/or subcortical ischemic stroke underwent the Cookie Theft picture description test and DTI up to three different time points: within the first three months, six months and twelve months after stroke. Dorsal and ventral stream language pathways were segmented to obtain DTI integrity metrics of both hemispheres. Multivariable regression models and partial correlation analyses adjusted for age, education, and lesion load were conducted to evaluate the temporal DTI profile of the white matter microstructural integrity of the language tracts as neural correlates of narrative speech within the first year after stroke. RESULTS: Among all the major language white matter pathways, the integrity of the left arcuate (AF), inferior fronto-occipital, and inferior longitudinal fasciculi (ILF) were related to picture description performance. After FDR correction, left ILF fractional anisotropy correlated with syntactic cohesiveness (r=0.85,p=0.00087) within the first three months after stroke, whereas at one year post-stroke, the strongest correlations were found between lexical-semantic performance and left AF radial diffusivity (r = -0.71, p = 0.00065). CONCLUSION: Our study provides a temporal profile of associations between the integrity of the main language pathways and lexical semantics and syntactic impairments in left hemispheric strokes.

Racial disparities in post-stroke functional outcomes in young patients with ischemic stroke.

BACKGROUND AND PURPOSE: Recent studies show rising incidence of stroke in the young, for which risk factors are not well characterized. There is evidence of increased risk in certain racial and ethnic groups. We assessed racial differences in risk factors, stroke etiology, and outcomes among young stroke patients. METHODS: Using data from our inpatient registry for ischemic stroke, we reviewed patients aged 18-50 who were admitted 01/2013 to 04/2018. Race/ethnicity were characterized as non-Hispanic White (NHW), non-Hispanic Black (NHB), Hispanic (HIS). For univariate comparisons Chi-square and Kruskal-Wallis tests were performed as appropriate. Multivariable logistic regression was used to assess impact of race on day seven modified Rankin score (mRS). RESULTS: Among 810 patients with race and outcome data who were admitted in the study period, median age was 43, 57.1% were male, and 36.5% NHW, 43.2% NHB, 20.2% HIS. History of hypertension (HTN), type II diabetes (DM II), smoking, heart failure (CHF), prior stroke, and end-stage renal disease varied significantly by race. Compared to NHW, NHB had higher odds of HTN (OR 2.28, 1.65-3.15), CHF (OR 2.17, 1.06-4.46), and DM II 1.92 (1.25-2.94) while HIS had higher odds of DM II (OR 2.52, 1.55-4.10) and lower odds of smoking (OR 0.56, 0.35-0.90). Arrival NIHSS was higher in NHB, but etiology and rates of tpA treatment and thrombectomy did not vary by race. Compared to NHW patients, NHB (OR 0.50 CI (0.31-0.78)) and HIS (OR 0.37 CI (0.21-0.67)) were less likely to have good functional outcome (mRS <2) at day 7 in adjusted analyses. CONCLUSIONS: In this study, there was a higher prevalence of several modifiable risk factors in NHB and HIS young stroke patients and early functional outcome was worse in these groups. Our study suggests a need for targeted prevention efforts for younger populations at highest risk for stroke.

Call to Action: SARS-CoV-2 and CerebrovAscular DisordErs (CASCADE).

BACKGROUND AND PURPOSE: The novel severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2), now named coronavirus disease 2019 (COVID-19), may change the risk of stroke through an enhanced systemic inflammatory response, hypercoagulable state, and endothelial damage in the cerebrovascular system. Moreover, due to the current pandemic, some countries have prioritized health resources towards COVID-19 management, making it more challenging to appropriately care for other potentially disabling and fatal diseases such as stroke. The aim of this study is to identify and describe changes in stroke epidemiological trends before, during, and after the COVID-19 pandemic. METHODS: This is an international, multicenter, hospital-based study on stroke incidence and outcomes during the COVID-19 pandemic. We will describe patterns in stroke management, stroke hospitalization rate, and stroke severity, subtype (ischemic/hemorrhagic), and outcomes (including in-hospital mortality) in 2020 during COVID-19 pandemic, comparing them with the corresponding data from 2018 and 2019, and subsequently 2021. We will also use an interrupted time series (ITS) analysis to assess the change in stroke hospitalization rates before, during, and after COVID-19, in each participating center. CONCLUSION: The proposed study will potentially enable us to better understand the changes in stroke care protocols, differential hospitalization rate, and severity of stroke, as it pertains to the COVID-19 pandemic. Ultimately, this will help guide clinical-based policies surrounding COVID-19 and other similar global pandemics to ensure that management of cerebrovascular comorbidity is appropriately prioritized during the global crisis. It will also guide public health guidelines for at-risk populations to reduce risks of complications from such comorbidities.

Mapping the trajectory of the amygdalothalamic tract in the human brain.

Although the thalamus is not considered primarily as a limbic structure, abundant evidence indicates the essential role of the thalamus as a modulator of limbic functions indirectly through the amygdala. The amygdala is a central component of the limbic system and serves an essential role in modulating the core processes including the memory, decision-making, and emotional reactions. The amygdalothalamic pathway is the largest direct amygdalo-diencephalic connection in the primates including the human brain. Given the crucial role of the amygdalothalamic tract (ATT) in memory function and diencephalic amnesia in stroke patients, diffusion tensor imaging may be helpful in better visualizing the surgical anatomy of this pathway noninvasively. To date, few diffusion-weighted studies have focused on the amygdala, yet the fine neuronal connection of the amygdala and thalamus known as the ATT has yet to be elucidated. This study aimed to investigate the utility of high spatial resolution diffusion tensor tractography for mapping the trajectory of the ATT in the human brain. We studied 15 healthy right-handed human subjects (12 men and 3 women with age range of 24-37 years old). Using a high-resolution diffusion tensor tractography technique, for the first time, we were able to reconstruct and measure the trajectory of the ATT. We further revealed the close relationship of the ATT with the temporopontine tract and the fornix bilaterally in 15 healthy adult human brains.