Neuroimaging Paradigms to Identify Patients for Reperfusion Therapy in Stroke of Unknown Onset.

Despite the proven efficacy of intravenous alteplase or endovascular thrombectomy for the treatment of patients with acute ischemic stroke, only a minority receive these treatments. This low treatment rate is due in large part to delay in hospital arrival or uncertainty as to the exact time of onset of ischemic stroke, which renders patients outside the current guideline-recommended window of eligibility for receiving these therapeutics. However, recent pivotal clinical trials of late-window thrombectomy now force us to rethink the value of a simplistic chronological formulation that "time is brain.

Comparison of Acute Ischemic Stroke Care and Outcomes Between Comprehensive Stroke Centers and Primary Stroke Centers in the United States.

Background: To improve stroke care, the Brain Attack Coalition recommended establishing primary stroke center (PSC) and comprehensive stroke center (CSC) certification. This study aimed to compare ischemic stroke care and in-hospital outcomes between CSCs and PSCs.

Methods And Results: We analyzed patients with acute ischemic stroke who were hospitalized at stroke centers participating in Get With The Guidelines-Stroke from 2013 to 2015.

Delays in the Air or Ground Transfer of Patients for Endovascular Thrombectomy.

Background And Purpose: For suspected large vessel occlusion patients efficient transfer to centers that provide endovascular therapy (ET) is critical to maximizing treatment opportunity. Our objective was to examine associations between transfer time, modes of transfer, ET, and outcomes within a hub-and-spoke telestroke network.

Methods: Patients with ischemic stroke were included if transferred to a single hub hospital between January 2011 and October 2015 with National Institutes of Health Stroke Scale>6, onset<12 hours from hub arrival with complete clinical, imaging, and transfer data.

Intravenous thrombolysis in unwitnessed stroke onset: MR WITNESS trial results.

Objective: Most acute ischemic stroke (AIS) patients with unwitnessed symptom onset are ineligible for intravenous thrombolysis due to timing alone. Lesion evolution on fluid-attenuated inversion recovery (FLAIR) magnetic resonance imaging (MRI) correlates with stroke duration, and quantitative mismatch of diffusion-weighted MRI with FLAIR (qDFM) might indicate stroke duration within guideline-recommended thrombolysis. We tested whether intravenous thrombolysis ≤4.

Teleneurology and mobile technologies: the future of neurological care.

Neurological disorders are the leading cause of global disability. However, for most people around the world, current neurological care is poor. In low-income countries, most individuals lack access to proper neurological care, and in high-income countries, distance and disability limit access.

Prestroke selective serotonin reuptake inhibitor use and functional outcomes after ischaemic stroke.

Background: Selective serotonin reuptake inhibitors (SSRIs) have been implicated in contributing to recovery after acute ischaemic stroke. In particular, poststroke initiation of an SSRI has been demonstrated to improve motor recovery. The role of prestroke SSRI use on functional outcomes and stroke recovery is less clear.

Implementation of a Rapid, Protocol-based TIA Management Pathway.

Introduction: Our goal was to assess whether use of a standardized clinical protocol improves efficiency for patients who present to the emergency department (ED) with symptoms of transient ischemic attack (TIA).

Methods: We performed a structured, retrospective, cohort study at a large, urban, tertiary care academic center. In July 2012 this hospital implemented a standardized protocol for patients with suspected TIA.

Diabetes and long-term outcomes of ischaemic stroke: findings from Get With The Guidelines-Stroke.

Aims: There is a paucity of data on the influence of diabetes on long-term outcomes after ischaemic stroke (IS). We assessed whether outcomes after IS differ between patients with and without diabetes.

Methods And Results: Patients aged ≥65 years (n = 409 060) in Get With The Guidelines-Stroke (nationwide registry of stroke patients from 1690 sites in the USA) were followed for 3 years post-discharge.

Absence of July Phenomenon in Acute Ischemic Stroke Care Quality and Outcomes.

Background: Lower care quality and an increase in adverse outcomes as a result of new medical trainees is a concept well rooted in popular belief, termed the "July phenomenon." Whether this phenomenon occurs in acute ischemic stroke has not been well studied.

Methods And Results: We analyzed data from patients admitted with ischemic stroke in 1625 hospitals participating in the Get With The Guidelines-Stroke program for the 5-year period between January 2009 and December 2013.

Validating the TeleStroke Mimic Score: A Prediction Rule for Identifying Stroke Mimics Evaluated Over Telestroke Networks.

Background And Purpose: Up to 30% of acute stroke evaluations are deemed stroke mimics, and these are common in telestroke as well. We recently published a risk prediction score for use during telestroke encounters to differentiate stroke mimics from ischemic cerebrovascular disease derived and validated in the Partners TeleStroke Network. Using data from 3 distinct US and European telestroke networks, we sought to externally validate the TeleStroke Mimic (TM) score in a broader population.

Association of Intracerebral Hemorrhage Among Patients Taking Non-Vitamin K Antagonist vs Vitamin K Antagonist Oral Anticoagulants With In-Hospital Mortality.

Importance: Although non-vitamin K antagonist oral anticoagulants (NOACs) are increasingly used to prevent thromboembolic disease, there are limited data on NOAC-related intracerebral hemorrhage (ICH).

Objective: To assess the association between preceding oral anticoagulant use (warfarin, NOACs, and no oral anticoagulants [OACs]) and in-hospital mortality among patients with ICH.

Design, Setting, And Participants: Retrospective cohort study of 141 311 patients with ICH admitted from October 2013 to December 2016 to 1662 Get With The Guidelines-Stroke hospitals.

Safety and Efficacy of a 3-Dimensional Stent Retriever With Aspiration-Based Thrombectomy vs Aspiration-Based Thrombectomy Alone in Acute Ischemic Stroke Intervention: A Randomized Clinical Trial.

Importance: The treatment effects of individual mechanical thrombectomy devices in large-vessel acute ischemic stroke (AIS) remain unclear.

Objective: To determine whether the novel 3-dimensional (3-D) stent retriever used in conjunction with an aspiration-based mechanical thrombectomy device (Penumbra System; Penumbra) is noninferior to aspiration-based thrombectomy alone in AIS.

Design, Setting, And Participants: This randomized, noninferiority clinical trial enrolled patients at 25 North American centers from May 19, 2012, through November 19, 2015, with follow-up for 90 days.

Frequent Hub-Spoke Contact Is Associated with Improved Spoke Hospital Performance: Results from the Massachusetts General Hospital Telestroke Network.

Background: For acute ischemic stroke patients, shorter time to thrombolytic (tissue plasminogen activator [tPA]) is associated with improved outcomes.

Introduction: Telestroke increases tPA use at spoke hospitals, yet its effect on door-to-needle (DTN) times for tPA administration is unknown. We hypothesize that spoke hospitals with more frequent contact to a hub hospital will have shorter DTN times than those with less frequent contact.

Experience with telemedicine in a multi-disciplinary ALS clinic.

Objective: Telemedicine using video televisits is emerging as a means to provide care directly to patients. Here we report our experience using video televisits to provide follow-up care as a part of the Massachusetts General Hospital (MGH) Telemedicine for People with ALS (TelePALS) initiative.

Methods: This was a retrospective chart review of all video televisit encounters conducted by the MGH ALS clinic between September 2014 and January 2016.

Visual Aids for Patient, Family, and Physician Decision Making About Endovascular Thrombectomy for Acute Ischemic Stroke.

Background And Purpose: Rapid decision making optimizes outcomes from endovascular thrombectomy for acute cerebral ischemia. Visual displays facilitate swift review of potential outcomes and can accelerate decision processes.

Methods: From patient-level, pooled randomized trial data, 100 person-icon arrays (Kuiper-Marshall personographs) were generated showing beneficial and adverse effects of endovascular thrombectomy for patients with acute cerebral ischemia and large vessel occlusion using (1) automated (algorithmic) and (2) expert-guided joint outcome table specification.

Ischemic Stroke Profile, Risk Factors, and Outcomes in India: The Indo-US Collaborative Stroke Project.

Background And Purpose: The Indo-US Collaborative Stroke Project was designed to characterize ischemic stroke across 5 high-volume academic tertiary hospitals in India.

Methods: From January 2012 to August 2014, research coordinators and physician coinvestigators prospectively collected data on 2066 patients with ischemic stroke admitted <2 weeks after onset. Investigator training and supervision and data monitoring were conducted by the US site (Massachusetts General Hospital, Boston).

Treatment and Outcome of Hemorrhagic Transformation After Intravenous Alteplase in Acute Ischemic Stroke: A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association.

Purpose: Symptomatic intracranial hemorrhage (sICH) is the most feared complication of intravenous thrombolytic therapy in acute ischemic stroke. Treatment of sICH is based on expert opinion and small case series, with the efficacy of such treatments not well established. This document aims to provide an overview of sICH with a focus on pathophysiology and treatment.

Characterizing New England Emergency Departments by Telemedicine Use.

Introduction: Telemedicine connects emergency departments (ED) with resources necessary for patient care; its use has not been characterized nationally, or even regionally. Our primary objective was to describe the prevalence of telemedicine use in New England EDs and the clinical applications of use. Secondarily, we aimed to determine if telemedicine use was associated with consultant availability and to identify ED characteristics associated with telemedicine use.

Is Risk-Standardized In-Hospital Stroke Mortality an Adequate Proxy for Risk-Standardized 30-Day Stroke Mortality Data? Findings From Get With The Guidelines-Stroke.

Background: Hospital profiling is typically undertaken using risk-standardized 30-day mortality, but obtaining these data for hospitals can be difficult. We sought to determine whether risk-standardized in-hospital mortality could serve as an adequate proxy for risk-standardized 30-day mortality data for the purposes of identifying outlier hospitals.

Methods And Results: Acute ischemic stroke cases entered into GWTG (Get With The Guidelines)-Stroke between 2003 and 2013 were linked to fee-for-service Medicare files to obtain 30-day mortality.

Increase in Endovascular Therapy in Get With The Guidelines-Stroke After the Publication of Pivotal Trials.

Background: Beginning in December 2014, a series of pivotal trials showed that endovascular thrombectomy (EVT) was highly effective, prompting calls to reorganize stroke systems of care. However, there are few data on how these trials influenced the frequency of EVT in clinical practice. We used data from the Get With The Guidelines-Stroke program to determine how the frequency of EVT changed in US practice.

Blood pressure and in-hospital outcomes in patients presenting with ischaemic stroke.

Aims: Post-stroke hypertension is associated with poor short-term outcome, although the results have been conflicting. Our objective was to evaluate the association of blood pressure (BP) and in-hospital outcomes in patients with acute ischaemic stroke.

Methods And Results: Patients in the Get With The Guidelines-Stroke registry with acute ischaemic stroke were included.