BACKGROUND AND AIMS:Prolonged monitoring with implantable cardiac monitors (ICMs) effectively detects subclinical atrial fibrillation (SCAF) in patients with cryptogenic stroke (CS). Understanding SCAF progression to higher burdens can affect decisions regarding oral anticoagulant (OAC) and antiarrhythmic therapies. This analysis aimed to quantify initial SCAF burden, its progression, and predictors of progression in CS patients. METHODS:This multicenter project collected demographics, stroke characteristics, and SCAF daily burden in CS patients implanted with ICM. SCAF progression was defined as an increase in daily burden from initial detection, categorized as: 5 min to 1 h, 1-6 h, 6-24 h, 24 h for < 7 days, and 24 h for ≥ 7 days. RESULTS:Of 593 patients (70.0 ± 11.3 years, 42% female, median CHA2DS2-VASc score 4.7 ± 1.4) monitored over a median of 24.6 months, 32.7% had SCAF detected. While initial SCAF daily burden was < 1 h in 38.7% of SCAF patients, 53.3% progressed to a higher SCAF daily burden, with 30.6% reaching the 24 h burden by 36 months. Higher CHA2DS2-VASc scores and stroke severity were associated with SCAF progression. OAC therapy was initiated in 91.2% patients with a maximum SCAF daily burden < 1 h, while in 98.0% of those with a maximum daily burden ≥ 1 h (p = 0.042). CONCLUSIONS:Over half of CS patients with SCAF progressed to a higher burden, and about one-third reached a 24 h SCAF daily burden. These findings highlight the importance of continuous monitoring in CS patients for early SCAF detection and personalized therapy, considering SCAF burden progression and the patient's risk profile.

BACKGROUND:Long-term continuous monitoring with insertable cardiac monitor (ICM) is recommended after cryptogenic stroke (CS) by current guidelines to detect subclinical atrial fibrillation (SCAF). However, long-term real-world data on ICM-SCAF detection and ensuing therapy are limited. The aim of this study was to assess long-term SCAF detection rate in a large cohort of CS patients with ICM. METHODS:Data of consecutive CS patients receiving ICM from September 2016 to February 2024 in 20 Italian centers were collected. Patients were followed with remote and outpatient follow-up according to clinical practice. SCAF was diagnosed if a device-detected SCAF daily burden ≥ 5 min was confirmed by a cardiologist. RESULTS:Seven hundred and eighty-nine CS patients with ICM (mean age 69.3 ± 11.7 years, 40.3% females, 79.0% CHA2DS2-VASc score ≥ 4) were monitored for a mean of 27.3 (IQR:14.2-42.5) months after index stroke. SCAF was diagnosed in 229 (29.0%) patients, with a cumulative detection rate of 37.0% (IQR: 32.9%-41.5%) 48 months after the stroke, and was asymptomatic in 198 (86.5%). Sixty-eight (29.7%) patients had one or more days with a 24-h SCAF burden. Median time from index stroke to SCAF diagnosis was 6.9 (IQR: 2.1-17.0) months. After SCAF diagnosis, anticoagulants were prescribed to 210 (95.9%) patients out of 219 not already assuming them at baseline. CHA2DS2-VASc ≥ 5, anterior circulation stroke, and cortical lesions were independent predictors of SCAF diagnosis. CONCLUSIONS:This multicenter real-world project confirmed that ICM allows the detection of SCAF in one third of CS patients 48 months after the stroke, leading to anticoagulation in most of them.

Importance:Cervical artery dissection (CeAD) is a leading cause of stroke in young people and can occur during pregnancy. In women with prior CeAD, it is unclear whether future pregnancies increase the risk of recurrent CeAD, stroke, or death. Objective:To compare the frequency of recurrent CeAD, stroke, or death as a composite outcome between patients with CeAD who became pregnant vs those who did not. Design, Setting, and Participants:The Long-Term Risk of Recurrent Cervical Artery Dissection and Stroke After Pregnancy (LONG-RECAP) study was an international, multicenter, registry-based, explorative cohort study with data from May 1, 1990, and April 30, 2023, among patients with CeAD at 33 stroke centers across 9 countries who had at least 6 months of follow-up for whom detailed information was available on absence vs presence of subsequent pregnancies and the occurrence of outcome events. Exposure:Pregnancy after CeAD. Main Outcomes and Measures:Composite of recurrent CeAD, stroke (any type), and death (all causes) during follow-up at least 6 months after initial CeAD. Secondary outcomes were the components of the composite outcome. Cox proportional hazards regression analysis with and without adjustment for age was used to examine the association between pregnancy and outcomes. Results:Among 1013 female patients with CeAD (median [IQR] age, 42 [35-48] years), 114 (11.3%) became pregnant during a median (IQR) follow-up of 5.3 (2.0-11.3) years. The composite outcome occurred in 10 of 114 patients (8.8%), including 7 patients with recurrent CeADs, 2 with ischemic strokes, and 1 with intracerebral hemorrhage, in the pregnancy group compared with 65 of 899 patients (7.2%), including 32 with recurrent CeAD, 26 with ischemic strokes, 4 with intracerebral hemorrhages, and 5 deaths (2 patients had 2 outcomes), in the nonpregnancy group (unadjusted hazard ratio, 1.08; 95% CI, 0.56-2.08; age-adjusted hazard ratio, 0.77; 95% CI, 0.38-1.56). Five of 10 events in the pregnancy group occurred post partum (4 CeADs and 1 stroke). Age-adjusted hazard ratios for secondary outcomes were 1.03 (95% CI, 0.43-2.46) for recurrent CeAD, 0.53 (95% CI, 0.13-2.12) for ischemic stroke, 1.01 (95% CI, 0.11-9.32) for intracerebral hemorrhage, and 0.90 (95% CI, 0.03-24.88) for death. Conclusions and Relevance:In this cohort study of women with a history of CeAD, becoming pregnant was not associated with an increased risk of recurrent CeAD, stroke, or death. These findings may be helpful for individual counseling and family planning for women with prior CeAD.

Abstract Background Results of previous trials about PFO closure as a treatment for migraine are still doubtful and inconclusive. We sought to evaluate the long–term (>10 years) effectiveness of migraine treatment by means of patent foramen ovale (PFO) closure. Methods From 2006 to 2010, 86 patients (68 female, mean age 40.0 ±3.7 years) with disabling, medication–refractory migraine and PFO were enrolled in a prospective study over a 48–month period. Criteria for transcatheter closure were all the following: presence of a permanent right–to–left shunt (RLS) having a shower/curtain pattern, presence of interatrial septal aneurysm and Eustachian valve, 3 to 4 class Migraine Disability Assessment Score (MIDAS), coagulation abnormalities, and medication–refractory migraine with or without aura. Results Forty patients (46.5%) (34 females, mean age 35.0±6.7 years, mean MIDAS 35.8 ± 4.7) underwent transcatheter closure. After a mean follow–up of 118.2 ±19.1 months (range 96 to 144), 37 patients continued the follow–up and experienced symptomatic improvement: aura was abolished in the totality of patients along with a durable improvement of migraine throughout the extended follow up also in patients without aura. The mean MIDAS significantly decreased in the closure group (p<0.0001) (Figure 1). Patients with complete migraine resolution presented a shorter history of migraine, a more severe thrombophilic profile, more severe RLS and larger left atrial diameter and volume. Conclusions Primary transcatheter PFO closure in selected high–risk patients having disabling refractory migraine resulted in abolition of aura and in a sustained reduction in migraine in the very long–term period.

To assess the efficacy of overnight pulse oximetry in screening male commercial drivers (CDs) for obstructive sleep apnea (OSA). Consecutive male CDs undergoing their annual scheduled occupational health visit were enrolled from ten transportation facilities. All subjects underwent a home sleep apnea test (HSAT) to determine the Respiratory Event Index (REI). Oxygen desaturation indices (ODIs) below the 3

INTRODUCTION:To evaluate the access to treatments with intravenous thrombolysis (IVT) and/or mechanical thrombectomy (MT) in acute ischemic stroke patients admitted to stroke units (SUs) of Veneto region (Italy) according to current "hub-and-spoke" model from 2017 to 2021.PATIENTS AND METHODS:We retrospectively analyzed data on treatments with IVT and/or MT for stroke patients admitted to the 23 SUs (6 Hubs and 17 Spokes) of the 6 macro-areas including 9 local sanitary units (LSUs) and 2 hospitals.RESULTS:We reported 6093 treatments with IVT alone, 1114 with IVT plus MT, and 921 with MT alone. Number of stroke unit (SU) beds/100,000 inhabitants ranges from 2.3 to 2.8, and no difference was found among different macro-areas. Number of treatments/100,000 inhabitants/year ranges from 19 to 34 for IVT alone, from 2 to 7 for IVT plus MT, and from 2 to 5 for MT alone. Number of IVT alone/SU bed/year ranges from 9 to 21 in the Hub and from 6 to 12 in the Spokes. Rate of IVT plus MT in patients directly arrived in the same LSU's Hub ranges from 50 to 81%, likewise the one of MT alone ranges from 49 to 84%.CONCLUSIONS:Treatment target rates of IVT and MT set by Action Plan for Stroke in Europe 2018-2030 has been globally exceeded in the Veneto region. However, the target rate of MT and access revascularization treatments is heterogeneous among different macro-areas. Further efforts should be made to homogenize the current territorial organization.

Background and Objectives Declines in stroke admission, IV thrombolysis (IVT), and mechanical thrombectomy volumes were reported during the first wave of the COVID-19 pandemic. There is a paucity of data on the longer-term effect of the pandemic on stroke volumes over the course of a year and through the second wave of the pandemic. We sought to measure the effect of the COVID-19 pandemic on the volumes of stroke admissions, intracranial hemorrhage (ICH), IVT, and mechanical thrombectomy over a 1-year period at the onset of the pandemic (March 1, 2020, to February 28, 2021) compared with the immediately preceding year (March 1, 2019, to February 29, 2020). Methods We conducted a longitudinal retrospective study across 6 continents, 56 countries, and 275 stroke centers. We collected volume data for COVID-19 admissions and 4 stroke metrics: ischemic stroke admissions, ICH admissions, IVT treatments, and mechanical thrombectomy procedures. Diagnoses were identified by their ICD-10 codes or classifications in stroke databases. Results There were 148,895 stroke admissions in the 1 year immediately before compared with 138,453 admissions during the 1-year pandemic, representing a 7% decline (95% CI [95% CI 7.1-6.9]; p < 0.0001). ICH volumes declined from 29,585 to 28,156 (4.8% [5.1-4.6]; p < 0.0001) and IVT volume from 24,584 to 23,077 (6.1% [6.4-5.8]; p < 0.0001). Larger declines were observed at high-volume compared with low-volume centers (all p < 0.0001). There was no significant change in mechanical thrombectomy volumes (0.7% [0.6-0.9]; p = 0.49). Stroke was diagnosed in 1.3% [1.31-1.38] of 406,792 COVID-19 hospitalizations. SARS-CoV-2 infection was present in 2.9% ([2.82-2.97], 5,656/195,539) of all stroke hospitalizations. Discussion There was a global decline and shift to lower-volume centers of stroke admission volumes, ICH volumes, and IVT volumes during the 1st year of the COVID-19 pandemic compared with the prior year. Mechanical thrombectomy volumes were preserved. These results suggest preservation in the stroke care of higher severity of disease through the first pandemic year.

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

Background and Objectives Declines in stroke admission, IV thrombolysis (IVT), and mechanical thrombectomy volumes were reported during the first wave of the COVID-19 pandemic. There is a paucity of data on the longer-term effect of the pandemic on stroke volumes over the course of a year and through the second wave of the pandemic. We sought to measure the effect of the COVID-19 pandemic on the volumes of stroke admissions, intracranial hemorrhage (ICH), IVT, and mechanical thrombectomy over a 1-year period at the onset of the pandemic (March 1, 2020, to February 28, 2021) compared with the immediately preceding year (March 1, 2019, to February 29, 2020). Methods We conducted a longitudinal retrospective study across 6 continents, 56 countries, and 275 stroke centers. We collected volume data for COVID-19 admissions and 4 stroke metrics: ischemic stroke admissions, ICH admissions, IVT treatments, and mechanical thrombectomy procedures. Diagnoses were identified by their ICD-10 codes or classifications in stroke databases. Results There were 148,895 stroke admissions in the 1 year immediately before compared with 138,453 admissions during the 1-year pandemic, representing a 7% decline (95% CI [95% CI 7.1–6.9]; p < 0.0001). ICH volumes declined from 29,585 to 28,156 (4.8% [5.1–4.6]; p < 0.0001) and IVT volume from 24,584 to 23,077 (6.1% [6.4–5.8]; p < 0.0001). Larger declines were observed at high-volume compared with low-volume centers (all p < 0.0001). There was no significant change in mechanical thrombectomy volumes (0.7% [0.6–0.9]; p = 0.49). Stroke was diagnosed in 1.3% [1.31–1.38] of 406,792 COVID-19 hospitalizations. SARS-CoV-2 infection was present in 2.9% ([2.82–2.97], 5,656/195,539) of all stroke hospitalizations. Discussion There was a global decline and shift to lower-volume centers of stroke admission volumes, ICH volumes, and IVT volumes during the 1st year of the COVID-19 pandemic compared with the prior year. Mechanical thrombectomy volumes were preserved. These results suggest preservation in the stroke care of higher severity of disease through the first pandemic year. Trial Registration Information This study is registered under NCT04934020.

BACKGROUND:Left atrial function is impaired in patients with patent foramen ovale. This study aimed to evaluate the role of left atrial function index in monitoring the course of left atrial function in a patient with patent foramen ovale before and after percutaneous closure.METHODS:We retrospectively reviewed the findings of consecutive patients evaluated in our tertiary center for patent foramen ovale closure to identify those subjects with acute ischemic stroke, transient ischemic attack, or radiological evidence of cerebral ischemic events (index event) who performed a complete echocardiography evaluation reporting evidence of patent foramen ovale between September 2004 and September 2018. The left atrial function was evaluated at baseline and then yearly using the left atrial function index.RESULTS:The cohort of 448 consecutive patients (mean age 43.4 ± 10.4 years, 257 males) was divided into 2 groups according to the temporal window between the index event and patent foramen ovale closure, defined as <1-year (216 patients) and ≥1-year (232 patients). Patients treated within 1 year from the index event maintained similar parameters of left atrial function and left atrial function index over the time, also after the interventional procedure. Conversely, patients treated after 1 year demonstrated a significant reduction of left atrial emptying function and maximal left atrial volume (P < .001 for all) compared to the basal values. The same parameters slightly increased after the percutaneous closure during the second year without reaching the basal values.CONCLUSIONS:Left atrial function index can be used as a non-invasive marker of atrial dysfunction severity in patients with patent foramen ovale before and after the interventional procedure.

Objective To explore the impact of antithrombotic therapy discontinuation in the postacute phase of cervical artery dissection (CeAD) on the mid-term outcome of these patients. Methods In a cohort of consecutive patients with first-ever CeAD, enrolled in the setting of the multicentre Italian Project on Stroke in Young Adults Cervical Artery Dissection, we compared postacute (beyond 6 months since the index CeAD) outcomes between patients who discontinued antithrombotic therapy and patients who continued taking antithrombotic agents during follow-up. Primary outcome was a composite of ischaemic stroke and transient ischaemic attack. Secondary outcomes were (1) Brain ischaemia ipsilateral to the dissected vessel and (2) Recurrent CeAD. Associations with the outcome of interest were assessed by the propensity score (PS) method. Results Of the 1390 patients whose data were available for the outcome analysis (median follow-up time in patients who did not experience outcome events, 36.0 months (25th-75th percentile, 62.0)), 201 (14.4%) discontinued antithrombotic treatment. Primary outcome occurred in 48 patients in the postacute phase of CeAD. In PS-matched samples (201 vs 201), the incidence of primary outcomes among patients taking antithrombotics was comparable with that among patients who discontinued antithrombotics during follow-up (5.0% vs 4.5%; p(log rank test)=0.526), and so was the incidence of the secondary outcomes ipsilateral brain ischaemia (4.5% vs 2.5%; p(log rank test)=0.132) and recurrent CeAD (1.0% vs 1.5%; p(log rank test)=0.798). Conclusions Discontinuation of antithrombotic therapy in the postacute phase of CeAD does not appear to increase the risk of brain ischaemia during follow-up.

Background: Implantable cardiac monitor (ICM) revealed subclinical atrial fibrillation (SCAF) in up to 30% of cryptogenic stroke (CS) patients in randomized trials. However, real world data are limited. Objectives: We investigated SCAF occurrence, treatments, clinical outcomes and predictors of SCAF in a multicenter real-world population subjected to ICM after CS. Methods: From September 2016 to November 2019, 20 Italian centers collected data of consecutive patients receiving ICM after CS and followed with remote and outpatient follow-up according to clinical practice. All device-detected AF events were confirmed by the cardiologist to diagnose SCAF. Results: ICM was implanted in 334 CS patients (mean age +/- SD 67.4 +/- 11.5 years, 129 (38.6%) females, 242 (76.1%) with CHA(2)DS(2)-VASC score >= 4). During a follow-up of 23.6 (IQR 14.6-31.5) months, SCAF was diagnosed in 92 (27.5%) patients. First episode was asymptomatic in 81 (88.1%). SCAF daily burden >5 minutes was 22.0%, 24.1% and 31.5% at 6, 12, and 24 months after ICM implantation. Median time to first day with AF was 60 (IQR 18-140) days. Female gender, age>69 years, PR interval>160 ms and cortical-subcortical infarct type at enrolment were independently associated with an increased risk of SCAF. Conclusions: In a real-world population, ICM detected SCAF in more than a quarter of CS patients. This experience confirms the relevance of implanting CS patients, for maximizing the possibilities to detect AF, following failure of Holter monitoring, according to guidelines. However, there is need to demonstrate that shift to oral anticoagulation following SCAF detection is associated with reduced risk of recurrent stroke.

We report the case of a 65 years-old female referred to our Emergency Department (ED) for acute onset of right hemiparesis-hypoesthesia with 7th right cranial nerve involvement. After hospitalization, oropharyngeal and nasopharyngeal swabs, she resulted positive for SARS-CoV-2. Magnetic resonance (MR) examination showed heterogeneous enhancing lesions in the basal ganglia and in the left temporal lobe surrounded by vasogenic edema. Even if perfusion weighted imaging (PWI) and MR spectroscopy were inconclusive for a glial tumor, it was initially considered the most probable diagnosis along with atypical infectious process. After 14 days of i.v. antibiotic and corticosteroid therapy, a second MR examination showed a significant reduction of the enhancing areas and the surrounding edema alongside transient improving clinical conditions. Nevertheless, multiple hemorrhagic foci appeared in the affected regions and in the right cerebral pedicle. Eventually, the patient died due to the worsening of intracranial hemorrhage. These findings led to the presumptive diagnosis of COVID-19-associated hemorrhagic necrotizing encephalopathy (ANE).

BACKGROUND AND PURPOSE Observational studies have suggested a link between fibromuscular dysplasia and spontaneous cervical artery dissection (sCeAD). However, whether patients with coexistence of the two conditions have distinctive clinical characteristics has not been extensively investigated. METHODS In a cohort of consecutive patients with first-ever sCeAD, enrolled in the setting of the multicenter IPSYS CeAD study (Italian Project on Stroke in Young Adults Cervical Artery Dissection) between January 2000 and June 2019, we compared demographic and clinical characteristics, risk factor profile, vascular pathology, and midterm outcome of patients with coexistent cerebrovascular fibromuscular dysplasia (cFMD; cFMD+) with those of patients without cFMD (cFMD-). RESULTS A total of 1283 sCeAD patients (mean age, 47.8±11.4 years; women, 545 [42.5%]) qualified for the analysis, of whom 103 (8.0%) were diagnosed with cFMD+. In multivariable analysis, history of migraine (odds ratio, 1.78 [95% CI, 1.13-2.79]), the presence of intracranial aneurysms (odds ratio, 8.71 [95% CI, 4.06-18.68]), and the occurrence of minor traumas before the event (odds ratio, 0.48 [95% CI, 0.26-0.89]) were associated with cFMD. After a median follow-up of 34.0 months (25th to 75th percentile, 60.0), 39 (3.3%) patients had recurrent sCeAD events. cFMD+ and history of migraine predicted independently the risk of recurrent sCeAD (hazard ratio, 3.40 [95% CI, 1.58-7.31] and 2.07 [95% CI, 1.06-4.03], respectively) in multivariable Cox proportional hazards analysis. CONCLUSIONS Risk factor profile of sCeAD patients with cFMD differs from that of patients without cFMD. cFMD and migraine are independent predictors of midterm risk of sCeAD recurrence.

Screening commercial drivers (CDs) for obstructive sleep apnea (OSA) reduces the risk of motor vehicle accidents. We evaluated the accuracy of standard OSA questionnaires in a cohort of CDs. We enrolled consecutive male CDs at 10 discrete transportation companies during their yearly scheduled occupational health visit. The CDs had their anthropometric measures taken; completed the Berlin, STOP, STOP-BANG, OSAS-TTI, SACS, EUROSAS, and ARES questionnaires; and underwent a home sleep apnea test (HSAT) for the determination of their respiratory events index (REI). We assessed the questionnaires’ ability to predict OSA (REI ≥ 5 events/h) and moderate-to-severe OSA (REI ≥ 15 events/h). Among 315 CDs recruited, 243 (77%) completed the study protocol, while 72 subjects were excluded for inadequate HSAT quality. The demographics and clinical data were comparable in both the included and excluded subjects. The included CDs had a median age of 50 years (interquartile range (IQR) 25–70) and a mean body mass index of 27 ± 4 kg/m2. One hundred and seventy-one subjects (71%) had OSA, and 68 (28%) had moderate-to-severe OSA. A receiver operating characteristic curve of the questionnaires were 0.51–0.71 for predicting OSA and 0.51–0.66 for moderate-to-severe OSA. The STOP-BANG questionnaire had an unsatisfactory positive predictive value, while all of the other questionnaires had an inadequate negative predictive value. Standard OSA questionnaires are not suited for screening among CDs. The use of the HSAT could provide an objective evaluation of for OSA in this special population.

OBJECTIVE:To measure the global impact of COVID-19 pandemic on volumes of IV thrombolysis (IVT), IVT transfers, and stroke hospitalizations over 4 months at the height of the pandemic (March 1 to June 30, 2020) compared with 2 control 4-month periods.METHODS:We conducted a cross-sectional, observational, retrospective study across 6 continents, 70 countries, and 457 stroke centers. Diagnoses were identified by their ICD-10 codes or classifications in stroke databases.RESULTS:There were 91,373 stroke admissions in the 4 months immediately before compared to 80,894 admissions during the pandemic months, representing an 11.5% (95% confidence interval [CI] -11.7 to -11.3, p < 0.0001) decline. There were 13,334 IVT therapies in the 4 months preceding compared to 11,570 procedures during the pandemic, representing a 13.2% (95% CI -13.8 to -12.7, p < 0.0001) drop. Interfacility IVT transfers decreased from 1,337 to 1,178, or an 11.9% decrease (95% CI -13.7 to -10.3, p = 0.001). Recovery of stroke hospitalization volume (9.5%, 95% CI 9.2-9.8, p < 0.0001) was noted over the 2 later (May, June) vs the 2 earlier (March, April) pandemic months. There was a 1.48% stroke rate across 119,967 COVID-19 hospitalizations. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection was noted in 3.3% (1,722/52,026) of all stroke admissions.CONCLUSIONS:The COVID-19 pandemic was associated with a global decline in the volume of stroke hospitalizations, IVT, and interfacility IVT transfers. Primary stroke centers and centers with higher COVID-19 inpatient volumes experienced steeper declines. Recovery of stroke hospitalization was noted in the later pandemic months.

The objectives of this study were to measure the global impact of the pandemic on the volumes for intravenous thrombolysis (IVT), IVT transfers, and stroke hospitalizations over 4 months at the height of the pandemic (March 1 to June 30, 2020) compared with two control 4-month periods.

ObjectiveTo assess the association of baseline imaging markers of cerebral small vessel disease (SVD) and brain frailty with clinical outcome after acute stroke in the Efficacy of Nitric Oxide in Stroke (ENOS) trial.MethodsENOS randomized 4,011 patients with acute stroke (<48 hours of onset) to transdermal glyceryl trinitrate (GTN) or no GTN for 7 days. The primary outcome was functional outcome (modified Rankin Scale [mRS] score) at day 90. Cognition was assessed via telephone at day 90. Stroke syndrome was classified with the Oxfordshire Community Stroke Project classification. Brain imaging was adjudicated masked to clinical information and treatment and assessed SVD (leukoaraiosis, old lacunar infarcts/lacunes, atrophy) and brain frailty (leukoaraiosis, atrophy, old vascular lesions/infarcts). Analyses used ordinal logistic regression adjusted for prognostic variables.ResultsIn all participants and those with lacunar syndrome (LACS; 1,397, 34.8%), baseline CT imaging features of SVD and brain frailty were common and independently associated with unfavorable shifts in mRS score at day 90 (all participants: SVD score odds ratio [OR] 1.15, 95% confidence interval [CI] 1.07-1.24; brain frailty score OR 1.25, 95% CI 1.17-1.34; those with LACS: SVD score OR 1.30, 95% CI 1.15-1.47, brain frailty score OR 1.28, 95% CI 1.14-1.44). Brain frailty was associated with worse cognitive scores at 90 days in all participants and in those with LACS.ConclusionsBaseline imaging features of SVD and brain frailty were common in lacunar stroke and all stroke, predicted worse prognosis after all acute stroke with a stronger effect in lacunar stroke, and may aid future clinical decision-making.IdentifierISRCTN99414122.