BACKGROUND:Recent years have seen improvements in stroke-care pathways, including mobile stroke units (MSUs), and this may have affected the rate, predictors, and outcomes of patients with acute ischemic stroke who qualify for but do not receive treatment with intravenous thrombolysis (IVT). METHODS:This was a secondary observational cohort analysis of the prospective, multicenter BEST-MSU trial (Benefits of Stroke Treatment Delivered by a Mobile Stroke Unit Compared With Standard Management by Emergency Medical Services), conducted in 7 US cities from 2014 to 2020, comparing MSU management versus standard emergency department management for patients with suspected acute ischemic stroke. The analytical cohort comprised enrolled patients with confirmed acute ischemic stroke and no guideline contraindications to IVT. The outcome was a potential missed IVT opportunity, defined as patients not treated with IVT despite lacking contraindications. We used multivariable logistic regression to evaluate whether demographics, prestroke modified Rankin Scale, study site, comorbidities, National Institutes of Health Stroke Scale, blood pressure, international normalized ratio, glucose, antithrombotic use, and thrombectomy were associated with this outcome. RESULTS:Of 1515 enrolled patients, 927 met criteria for this analysis. Fifty-one participants (5.5%) had a potential missed IVT opportunity, including 4 of 555 (0.7%) in the MSU group versus 47 of 372 (12.6%) in the emergency department group (odds ratio, 0.05 [95% CI, 0.02-0.12]). In multivariable analysis, omitting study group, lower National Institutes of Health Stroke Scale (odds ratio, 0.95 [95% CI, 0.90-0.99]) and longer last known well-to-door time (odds ratio per 10 minutes, 1.08 [95% CI, 1.03-1.13]) were independently associated with a potential missed IVT opportunity. The leading reasons documented for withholding IVT were resolving symptoms (43%), time window concerns (18%), and minor deficits (10%). Among participants with a potential missed IVT opportunity and a recorded 3-month modified Rankin Scale (n=49), 19 (39%) had a score of 3 to 6. CONCLUSIONS:In the BEST-MSU trial, potential missed IVT opportunities occurred in 1-in-8 patients in the emergency department, and rarely on the MSU. Although often due to early improvement or minor deficits, more than one-third of these patients had poor functional status at 3 months. REGISTRATION:URL: https://www.clinicaltrials.gov; Unique identifier: NCT02190500.

BACKGROUND:The authors present an overview of the current evidence and management recommendations for evaluation and treatment of adults with acute ischemic stroke from distal- and medium-vessel occlusion (DMVO) for endovascular thrombectomy (EVT). The intended audiences are prehospital care providers, physicians, and allied health professionals. METHODS:The Society of Vascular and Interventional Neurology Guidelines and Practice Standards committee formed a writing group to conduct a structured literature review on EVT for DMVO-related acute ischemic stroke and to draft practice recommendations in accordance with the Society of Vascular and Interventional Neurology Guidelines and Practice Algorithm. A structured literature search was conducted across PubMed, MEDLINE, and the Cochrane Library from January 2015 through February 2026, supplemented by manual review of reference lists from key studies and conferences. Recommendations were developed with consensus from an expert panel and the Guidelines and Practice Standards committee, with final approval by the Society of Vascular and Interventional Neurology Board of Directors. RESULTS:Data from all randomized controlled trials, prior meta-analyses, and subgroup analyses were extracted to evaluate the latest evidence on the safety and efficacy of EVT in patients presenting with DMVO acute ischemic stroke. The guideline outlines practical considerations for patient selection, procedural technique, and systems of care. CONCLUSIONS:These guidelines provide focused practical recommendations based on recent evidence regarding patient selection and decision-making for EVT in patients presenting with acute DMVO. Routine EVT for DMVO is not supported by current evidence; however, performing EVT in patients with disabling acute dominant M2 occlusion remains reasonable.

AIM:The "2026 Guideline for the Early Management of Patients With AIS" replaces the "2018 Guidelines for the Early Management of Patients With AIS" and the 2019 update to reflect recent advances in evidence. This updated guideline is intended to provide a comprehensive, up-to-date, evidence-based set of recommendations, advising management from prehospital evaluation through acute treatment and early in-hospital management of complications and initiation of early secondary prevention measures. The intended audience includes prehospital care professionals, physicians, allied health professionals, and hospital administrators. METHODS:A search for literature derived from research principally involving human subjects, published in English since the last AIS guideline in 2018 and the 2019 update, and indexed in MEDLINE, PubMed, Cochrane Library, and other selected databases relevant to this guideline, was conducted between September and December 2024. Additional high impact studies and articles published through March 2025 were added later, where appropriate. STRUCTURE:This guideline represents the most current and comprehensive evidence available in AIS care. Key updates include the incorporation of new evidence related to thrombolytic choice and eligibility, determination of eligibility for endovascular thrombectomy, and management of hyperglycemia and dysphagia; a focused consideration of the pediatric population; and modification of the approach to thrombolysis contraindications. Although this guideline reflects significant advances, it also highlights gaps in knowledge and underscores the urgent need for continued research to further refine and improve treatment strategies.

BACKGROUND:Glenzocimab, a platelet glycoprotein VI antagonist, is a novel agent that inhibits platelet activation and aggregation. Its safety was demonstrated in the ACTIMIS trial (Acute Ischemic Stroke Interventional Study; URL: https://www.clinicaltrials.gov; Unique identifier: NCT03803007) for patients with stroke receiving thrombolysis, with or without mechanical thrombectomy, and results suggested a reduction in intracranial hemorrhages and mortality. The ACTISAVE trial was designed as a confirmatory study to evaluate the efficacy and safety of glenzocimab in acute ischemic stroke.METHODS:ACTISAVE (Acute Ischemic Stroke Study Evaluating Glenzocimab Used as Add-On Therapy Versus Placebo) was an international, randomized, double-blind, placebo-controlled phase 2/3 study in patients with stroke, treated by thrombolysis within 4.5 hours of symptoms onset with or without mechanical thrombectomy. The study was conducted at 54 primary and comprehensive stroke centers located in 10 countries. Patients were randomized 1:1 to glenzocimab (1000 mg-IV) or placebo. The primary outcome was the modified Rankin Scale (mRS) score of 4 to 6 at day 90. Key secondary outcome was the mRS score of 0 to 2 at day 90. Mortality, mRS shift, National Institutes of Health Stroke Scale score, quality of life, and safety outcomes were assessed.RESULTS:Between September 2021 and October 2023, 438 patients were randomized, 421 treated, and included as randomized in the primary analysis set. Median age was 73 (63-80) years, and 43% were female. Thrombolysis was performed 2.3 hours (median) after symptom onset and followed by mechanical thrombectomy in 36% of patients. The assigned treatment began a median of 1.2 (interquartile range, 0.8-1.6) hours after thrombolysis initiation. Prethrombolysis National Institutes of Health Stroke Scale score median was 9 (6-15). At day 90, there was no statistically significant difference in the primary outcome between the treatment groups: the incidence of poor outcome (mRS score 4-6 versus 0-3) was 21.6% in the glenzocimab group compared with 15.3% placebo group (odds ratio, 1.51 [95% CI, 0.90-2.54]; P=0.120). No statistically significant difference in secondary outcomes was observed. There were no major safety signals with any intracerebral hemorrhage occurring respectively in 60 (28.6%) and 63 (29.9%) patients in glenzocimab and placebo arms.CONCLUSIONS:ACTISAVE failed to confirm a beneficial effect of glenzocimab on mRS in patients with acute ischemic stroke treated by thrombolysis.REGISTRATION:URL: https://www.clinicaltrials.gov; Unique identifier: NCT05070260.

BACKGROUND:For stroke patients with history of possible Direct Acting Oral Anticoagulant use, clinicians must make treatment decisions without knowledge of whether the patient is therapeutically anticoagulated. A urine-based point-of-care test might help guide these emergency decisions. METHODS:We prospectively enrolled patients with suspected recent factor-Xa-inhibitor (Xai) use being evaluated for acute stroke therapy in an urban teaching hospital. We obtained the urine test and plasma anti-Xa level in parallel with usual clinical management; the treating clinician did not use test results for decision-making but recorded treatment they would have given had they known the urine test was accurate. The primary outcome was feasibility. Secondary outcomes were accuracy of the urine test at plasma anti-Xa level >30 ng/mL and consequent change in clinical management. RESULTS:Twenty-one patients were enrolled over 1 year. The urine test was successfully carried out in all patients, median 59 minutes after Emergency Department arrival. Sensitivity and specificity for the urine test to detect threshold anti-Xa activity were 100 % and 87.5 %. Of 20 patients with ischemic stroke, none of whom were treated with thrombolytics, 6 had a negative test which would have resulted in treatment of 4 (66 %). CONCLUSION:A urine point-of-care test for Xai activity is feasible, accurate, and would likely result in treatment of stroke patients currently excluded from thrombolysis.

Background: Racial and ethnic disparities in stroke exist across the continuum of care, including prehospital care. The impact of Mobile Stroke Units (MSUs) on racial disparities in thrombolytic treatment metrics is not reported. Methods: A pre-specified sub-study of ischemic stroke patients enrolled in BEST-MSU was conducted. MSU and standard management (SM) groups were divided into Non-Hispanic White (NHW), Non-Hispanic Black (NHB), and Hispanic (H) cohorts. Other racial groups were excluded (small n). Primary outcome was last seen normal to tPA time . Secondary outcomes included 90-day utility-weighted modified Rankin Scale (uw-mRS), functional independence (mRS 0-1), and mortality. Results: A total of 1420 patients were included: 557 NHW, 586 NHB, and 277 H. NHB and H groups were younger, had lower education, and higher proportions uninsured. In SM, NHB and H patients received slower care and less frequent tPA compared to NHW (Table 1). In contrast, MSU management reduced time to treatment (19 min NHW vs 46.5 min NHB vs 46 min H; p=<0.001) in NHB and H, and led to more frequent tPA (13% more NHW, 11% more NHB, 25% more H) in H. MSU management was associated with better uw-mRS across all groups (Figure 1). More functional independence was seen in NHW and NHB (adjusted OR NHW 1.79 [1.10-2.95] p=0.019; NHB 2.13 [1.38-3.33] p=0.0007). Mortality benefit was seen in H (p=0.03). Conclusion: MSUs overcome known disparities in thrombolytic utilization and treatment metrics in Non-Hispanic Black and Hispanic groups. Further studies are needed to evaluate care inequities that are overcome through integration of a MSU into the prehospital setting.

Background: Migraine prevalence has been estimated to be as high as 25% during reproductive years. Despite this, and the known significantly lower odds of acute stroke being correctly diagnosed among women versus men, little is known about the migraine-stroke connection in this vulnerable population. Our study seeks to provide a consolidated examination of cerebrovascular and obstetric complications of migraines in pregnant women and to evaluate the role of concurrent comorbidities.Methods: We utilized the 2016-2020 Healthcare Cost and Utilization Project's National Inpatient Sample with the International Classification of Diseases, 10th Revision diagnostic codes to compare pregnant patients with migraines with those without migraines. Multivariable logistic regression was used to examine the incidence of subtypes of stroke while controlling for confounding variables.Results: Overall, 19,825,525 pregnant patients were evaluated; 219,175 (1.1%) had a concomitant diagnosis of migraine. Pregnant patients with migraines were more likely to suffer ischemic (0.1% versus 0.0%) or hemorrhagic stroke (0.3% versus 0.1%). On multivariate analysis, acute ischemic stroke was most strongly associated with migraine with aura (odds ratio [OR], 23.26; 95% confidence interval [CI], 18.46-29.31), followed by migraine without aura (OR, 8.15; 95% CI, 4.79-13.88).Conclusions: Pregnant women with migraine are at a significantly increased risk for both ischemic and hemorrhagic stroke. Pregnant women with migraines should be cautioned that they may be at an increased risk of stroke, particularly if they are experiencing an aura, and encouraged to contact their medical providers to rule out neurological complications.

Background: Mobile stroke units (MSUs) improve outcomes in thrombolytic-eligible ischemic stroke patients. Outcomes of MSU management in patients with intracranial hemorrhage (ICH) have not been reported. Methods: We conducted a retrospective review of ICH patients enrolled in the Benefits of Stroke Treatment Using a Mobile Stroke Unit (BEST-MSU), a prospective multicenter controlled trial comparing MSU with standard EMS management (SM). The primary outcome was utility weighted modified Rankin Scale (uw-mRS) at 90 days; secondary outcomes were hematoma expansion, length of inpatient stay, favorable discharge disposition or 90-day mRS, and mortality. Groups were compared using Chi-square or Fisher’s exact tests for categorical variables, and two sample t-test or Wilcoxon rank sum test for continuous variables. Adjusted analysis was performed to evaluate the relationship between the intervention group and uw-mRS at 90 days. Kaplan-Meier curves and log-rank test were used to compare the survival by 90 days between groups. Results: 201 ICH patients were identified; 102 in the MSU and 99 in the SM groups. MSU patients had more antiplatelet/antithrombotic (AP/AT) use (30.4% vs 15.2%, p=0.016); edema was more frequent in the SM group (72.7% vs 52.0%, p = 0.004). Initial ICH volume was similar between MSU and SM groups (11.50 mL [5.0, 22.0] vs. 9.0 mL [5.0, 20.0], p = 0.62). Anti-hypertensives were given earlier on the MSU (39.0 min [31.00, 45.00] vs 61.0 min [46.50, 75.25], p<0.001), and resulted in shorter time to systolic blood pressure (SBP) < 150mmHg (52 min vs. 121 min, p<0.001). The mean uw-mRS at 90 days was 0.364 ± 0.361 in the MSU and 0.465 ± 0.360 in the SM group (p=0.50, adjusted for AP/AT and edema). There was no difference in hematoma expansion, length of stay, discharge disposition or 90-day mRS. Higher mortality was noted after 5 days post-ictus in the MSU group (26.5% vs. 14.1%, p = 0.04). Conclusion: In ICH patients, MSU management resulted in faster treatment and time to target SBP with similar clinical outcomes except higher late mortality. Further study of the impact of prehospital ICH management including BP reduction and AT/AP reversal are required.

OBJECTIVE:Given the high disease and cost burden of ischemic stroke, evaluating the clinical efficacy and cost-effectiveness of new approaches to prevent and treat ischemic stroke is critical. Effective ischemic stroke management depends on timely administration of thrombolytics after stroke onset. This study evaluates the cost-effectiveness associated with the use of mobile stroke units (MSUs) to expedite tissue plasminogen activator (tPA) administration, as compared with standard management through emergency medical services (EMS). METHODS:This study is a prospective, multicenter, alternating-week, cluster-controlled trial of MSU versus EMS. One-year and life-time cost-effectiveness analyses, using the incremental cost-effectiveness ratio (ICER) method, were performed from the perspective of CMS's Medicare. Quality-adjusted life years (QALYs) estimated using patient-reported EQ-5D-5L data were used as the effectiveness measure. Health care utilizations were converted to costs using average national Medicare reimbursements. ICERs excluding patients with pre-existing disability, and limited to stroke-related costs were also calculated. RESULTS:The first-year ICER for all tPA-eligible patients using total cost differences between MSU and EMS groups was $238,873/QALY; for patients without pre-existing disability was $61,199/QALY. The lifetime ICERs for all tPA-eligible patients and for those without pre-existing disability were $94,710 and $31,259/QALY, respectively. All ICERs were lower when restricted to stroke-related costs and were highly dependent on the number of patients treated per year in an MSU. INTERPRETATION:MSUs' cost-effectiveness is borderline if we consider total first-year costs and outcomes in all tPA-eligible patients. MSUs are cost-effective to highly cost-effective when calculations are based on patients without pre-existing disability, patients' lifetime horizon, stroke-related costs, and more patients treated per year in an MSU. ANN NEUROL 2025;97:209-221.

Intravenous thrombolysis (IVT) may be administered to stroke patients requiring immediate treatment more quickly than emergency medical services if certain conditions are met. These conditions include the presence of mobile stroke units (MSUs) with on-site treatment teams and a computed tomography scanner. We compared clinical outcomes of MSU conventional therapy by emergency medical services through a systematic review and meta-analysis. We searched key electronic databases from inception till September 2021. The primary outcomes were mortality at 7 and 90 days. The secondary outcomes included the modified Rankin Scale score at 90 days, alarm to IVT or intra-arterial recanalization, and time from symptom onset or last known well to thrombolysis. We included 19 controlled trials and cohort studies to conduct our final analysis. Our comparison revealed that 90-day mortality significantly decreased in the MSU group compared with the conventional care group [risk ratio = 0.82; 95% confidence interval (CI), 0.71-0.95], while there was no significant difference at 7 days (risk ratio = 0.89; 95% CI, 0.69-1.15). MSU achieved greater functional independence (modified Rankin Scale = 0-2) at 90 days (risk ratio = 1.08; 95% CI, 1.01-1.16). MSU was associated with shorter alarm to IVT or intra-arterial recanalization time (mean difference = -29.69; 95% CI, -34.46 to -24.92), treating patients in an earlier time window, as shown through symptom onset or last known well to thrombolysis (mean difference = -36.79; 95% CI, -47.48 to -26.10). MSU-treated patients had a lower rate of 90-day mortality and better 90-day functional outcomes by earlier initiation of IVT compared with conventional care.

Background: Enrollment into hyperacute stroke trials may be constrained since candidates are usually not identified until they arrive in the emergency department. Pre-hospital identification may increase and speed study enrollment. Methods: Midway through the Multi-Arm Optimization of Stroke Thrombolysis (MOST) trial, our mobile stroke unit research personnel monitored EMS radio for potential stroke patients en route to our study hospital. Time of onset, symptoms, and expected arrival time were relayed to the MOST research team, who met the patient upon ED arrival. Expected site enrollment was 1 patient per month. Results: The rate of trial enrollment before intervention (10/2019 - 11/2021) was 0.8 patients per month compared to 2.4 after intervention (12/2021 - 07/2023), 2.43, 95% CI: 1.48-4.10, p<0.01 - see figure. In addition, there was a 17.5-minute reduction in ED arrival to trial randomization (88 vs. 70.5 minutes). Conclusion: Pre-hospital screening tripled the rate of trial recruitment and can help overcome challenges when enrolling participants in hyperacute clinical trials.

Introduction The recently published CHOICE trial found that intra‐arterial infusion of alteplase improved clinical outcomes in patients undergoing EVT for LVO AIS, an effect that was possibly due to a reduction in reperfusion‐related injury. Here, we examine whether intravenous alteplase, administered after successful endovascular reperfusion, results in improved clinical outcomes. Methods From our prospectively collected multicenter institutional registry drawn from four comprehensive stroke centers in the greater Houston area, we identified cases who underwent EVT with substantial reperfusion (TICI 2b/3) prior to termination of the intravenous alteplase continuous drip. Control patients were then identified as patients who underwent EVT with TICI 2b/3 after completion of intravenous alteplase, matching on age, baseline Modified Rankin Scale (mRS), initial NIH Stroke Scale (NIHSS), and comorbidities. The primary outcome was 90 day disability and was determined by mRS shift analysis, comparing the case and control populations. Results Among 21 cases and 24 matched controls, there were no significant difference between the mean age, gender, race, initial NIHSS, baseline mRS, or ASPECT score. Time from last known well to recanalization was longer in controls (48 min vs 151 min, p< 0.01). Patients who achieved reperfusion prior to termination of the alteplase continuous drip had better 90 day clinical outcomes relative to their presentation mRS when compared to patients who achieved reperfusion after termination of the alteplase. A change in mRS of 1 or less was seen in 71% vs 33% in the continued infusion group vs controls respectively. Conclusions Patients undergoing EVT who continued to be treated with intravenous alteplase following reperfusion had better 90d clinical outcomes relative to those with reperfusion after infusion termination. These findings further support the possible efficacy of thrombolytics following endovascular reperfusion.

Background Clinical and radiographic outcomes after mechanical thrombectomy in the setting of COVID‐19 infection remain poorly characterized. We sought to determine how COVID‐19 status affects mechanical thrombectomy outcomes in the real‐world setting in the United States. Methods The prospectively maintained multicenter mechanical thrombectomy registry from the Society of Vascular and Interventional Neurology was queried for baseline clinical characteristics among patients with and without COVID‐19 who underwent mechanical thrombectomy between March 1 and December 31, 2020 at 12 sites. Primary outcome was the likelihood of good neurological outcomes (90 day modified Rankin scale 0–2) among patients with COVID‐19 treated with endovascular thrombectomy, which was assessed using multivariable logistic regression adjusted for age, National Institutes of Health Stroke Scale, Alberta Stroke Program Early CT Score, and substantial reperfusion (modified Thrombolysis in Cerebral Infarction 2b, 2c, and 3). Secondary outcomes included National Institutes of Health Stroke Scale at 24 hours. Results Among 915 patients who underwent mechanical thrombectomy during the study period, 51 patients were positive for COVID‐19 (5.6%). Univariate analysis revealed that compared with patients who were COVID‐19 negative, patients who were positive for COVID‐19 were more likely to be male, nonsmokers, have lower Alberta Stroke Program Early CT Score, and present with intracranial internal carotid artery occlusions (Table 1). They were also less likely to achieve successful reperfusion. Multivariable analysis, however, failed to identify any independent associations with COVID‐19 positive status. Conclusion In our cohort, patients postive for COVID‐19 with acute ischemic stroke who undergo mechanical thrombectomy have similar baseline characteristics, imaging features, procedural, and clinical outcomes compared to patients who are negative for COVID‐19 in multivariate analysis. Further analyses are warranted.

Introduction: While the goal of IV tissue plasminogen activator (TPA) is to prevent infarction, few data exist on averted stroke. Methods: Secondary analysis of a multicenter trial from 2014-2020 comparing outcomes between patients treated for stroke by mobile stroke unit (MSU) vs standard care (SC). The analytical cohort were patients with suspected stroke treated with IV TPA. The primary outcome was a time-defined averted stroke diagnosis, defined as a final diagnosis of stroke with resolution of presenting symptoms/signs by 24 hours. The secondary outcome was a tissue-defined averted stroke diagnosis, defined as a final diagnosis of stroke with resolution of presenting symptoms/signs by 24 hours and no acute infarction/hemorrhage on imaging. We used multivariable logistic regression to evaluate associations between study exposures (demographics, comorbidities, stroke characteristics) and outcomes. Results: Among 1009 patients with a median last known well-to-TPA time of 87 minutes, 276 patients (27%) had a time-defined averted stroke (31% MSU, 21% SC) and 159 patients (16%) had a tissue-defined averted stroke (18% MSU, 11% SC). Factors independently associated with time-defined averted stroke were younger age (OR, 0.98; 95% CI, 0.96-0.99), female sex (0R, 0.51; 95% CI, 0.36-0.74), hyperlipidemia (OR, 1.81, 95% CI, 1.24-2.64), normal premorbid function (0R, 2.22; 95% CI, 1.37-3.67), lower glucose (OR, 0.996; 95% CI, 0.993-0.999), lower MAP (OR, 0.991; 95% CI, 0.983-0.998), MSU care (OR, 1.77; 95% CI, 1.21-2.62), lower NIH stroke scale (OR, 0.89; 95% CI, 0.86-0.93), and no large vessel occlusion (LVO) (OR, 0.52; 95% CI, 0.32-0.83). For tissue-based averted stroke, younger age, female sex, hyperlipidemia, lower MAP, MSU treatment, lower NIH stroke scale, and no LVO were significantly associated. Conclusion: In a modern acute stroke trial, one-in-four patients treated with TPA for stroke recovered within 24 hours and one-in-six had no demonstrable brain injury on imaging. Younger age, female sex, hyperlipidemia, lower MAP, MSU care, lower stroke severity, and no LVO may increase the odds of averting stroke.

Background The impact of mobile stroke units (MSUs) on outcomes in patients with large vessel occlusions eligible for endovascular thrombectomy (EVT) has yet to be characterized. Methods We completed a prespecified substudy of patients with EVT‐eligible stroke with anterior and posterior circulation large vessel occlusions on computed tomography and/or computed tomography angiography who were enrolled in BEST‐MSU (Benefits of Stroke Treatment using a Mobile Stroke Unit). Primary outcome was 90‐day utility‐weighted modified Rankin scale. Groups were compared using chi‐square or Fisher's exact tests for categorical variables, and 2‐sample t‐tests for continuous variables. Multiple logistic regression was used to assess the effect of MSU on binary outcomes after adjusting for other baseline factors. Results Of 1515 trial patients, 293 had large vessel occlusions eligible for EVT: 168 in the MSU group and 125 in the emergency medical services group. Baseline characteristics were comparable, with the exception of baseline National Institutes of Health Stroke Scale score (MSU median 19 [interquartile range 13, 23] versus emergency medical services 16 [11, 20], P = 0.002) and study site. The mean (±SD) score on the utility‐weighted modified Rankin scale at 90 days was 0.63±0.39 in MSU group and 0.51±0.41 in emergency medical services group (mean difference 0.13, 95% CI [0.03–0.22]). After adjustment, MSU had significantly higher odds of functional independence (odds ratio 2.60 [95% CI, 1.45–4.77], P = 0.002). Secondary outcomes also favored MSU: early neurologic recovery (30% improvement in National Institutes of Health Stroke Scale score at 24 hours) 68% versus 52%; adjusted odds ratio 1.98 [95% CI, 1.19–3.33]; time of tissue plasminogen activator bolus from symptom onset 65.0 minutes [50.5–92.0] versus 96.0 [79.3–130.0], P≤0.001. The groups had similar onset to arterial puncture (169.0 minutes [133.5, 210.0] versus 162.0 [135.0–207.0], P = 0.83). Conclusions In patients with EVT‐eligible large vessel occlusion stroke, MSU management was associated with better clinical outcomes compared with standard emergency medical services management. MSU management sped thrombolysis but did not expedite EVT treatment times. Future MSU processes should include efforts to capitalize on the potential of MSUs to provide earlier EVT.

Objective: Evaluate the impact of a direct-to-angiosuite (DTAS) workflow on Mobile Stroke Units (MSU) in stroke patients with large vessel occlusions (LVO) needing mechanical thrombectomy (MT). Background: MSUs are equipped with CT/CT angiography (CTA), thrombolytics and personnel that can deliver emergency stroke care to patients and reduce time-to-thrombolytic administration and improve clinical outcomes. Although there is no benefit of MSUs on alert-to-puncture times, a reduction in time was seen when CTA was obtained on-board the MSU, which suggests that a DTAS protocol may be a powerful method to reduce delay from alert-to-puncture. Design/Methods: The MSU DTAS group will be comprised of suspected LVO patients having CTA on-board the MSU, alerting of the MT team en route, and bypassing the Emergency Department (ED) with direct transport to the angiosuite. The control group will comprise of the standard Emergency Medical Services (EMS) management group from the BEST-MSU study. In those patients, CTA was done after arrival to the ED and then transported to the angiosuite. Primary outcome will be alert-to-puncture time. Secondary outcomes will include 90-day modified Rankin scale and degree of recanalization. Analysis of the mRS will be a propensity-score based ordinal logistic regression adjusted for baseline predictors to estimate the common odds ratio. Based on pilot data, we estimate we will detect at least a 30-minute reduction in alert-to-puncture time. Results: In a preliminary analysis of the BEST-MSU study, DTAS management resulted in shorter alert-to-puncture (42 minutes) and door-to-puncture times (50 minutes) with similar safety and clinical outcomes compared with standard management. We plan to enroll additional patients to the MSU DTAS pathway and a more detailed and final analysis will be available upon abstract presentation at the AAN conference. Conclusions: A DTAS workflow, triggered by CTA on MSU patients suspected of having LVO, substantially speeds alert-to thrombectomy, and may improve recanalization and clinical outcome. Disclosure: Dr. Tariq has nothing to disclose. Stephanie Parker has nothing to disclose. Dr. Jacob has nothing to disclose. Mengxi Wang has nothing to disclose. Noopur Singh has nothing to disclose. The institution of Jose-Miguel Yamal has received research support from NIH/DoD. Mr. Phan has nothing to disclose. Ms. Bratina has nothing to disclose. Dr. Bowry has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Astrazeneca. Dr. Grotta has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for Frazer Ltd. Dr. Grotta has received personal compensation in the range of $5,000-$9,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Haemonetics. Dr. Grotta has received personal compensation in the range of $10,000-$49,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Acticor. Dr. Grotta has received personal compensation in the range of $5,000-$9,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Prolong Pharma. The institution of Dr. Grotta has received research support from Genentech. The institution of Dr. Grotta has received research support from CSL Behring. The institution of Dr. Grotta has received research support from Chiesi. Dr. Grotta has received publishing royalties from a publication relating to health care. Dr. Grotta has received publishing royalties from a publication relating to health care. The institution of Dr. Czap has received research support from SVIN. The institution of Dr. Czap has received research support from AAN.

Introduction Mobile Stroke Units (MSUs) speed treatment with tPA, but did not affect time from alert to puncture time for endovascular therapy (EVT) in the Benefits of Stroke Treatment Using a Mobile Stroke Unit (BEST‐MSU), a prospective multicenter controlled trial comparing MSU with standard EMS management. The lack of improvement in EVT treatment time could be because the CTA to identify large vessel occlusions (LVOs), and alerting of the EVT team, were delayed in most MSU patients until after Emergency Department (ED) arrival. The impact of identifying LVOs by imaging on the MSU enabling a direct (from MSU) to angiosuite (DTAS) protocol has yet to be studied. Methods We conducted a pre‐specified substudy of tPA‐eligible stroke patients with LVOs on computed tomography (CT) and/or CT angiography (CTA) who were enrolled into the MSU arm of the BEST‐MSU study. We compared alert to puncture time and other process metrics, mean utility‐weighted modified Rankin Scale (uw‐mRS) and functional independence (mRS 0–2) at 90 days, and rate of early neurologic recovery (30% improvement in NIHSS score) at 24 hours in patients who were managed by DTAS vs post‐ED arrival diagnosis and alerting. Results A total of 169 MSU patients with LVOs were identified; 22 in the DTAS group and 111 in the non DTAS group. Data were not available for 36 LVO patients. Baseline characteristics including age, sex, ethnicity, prestroke mRS, and initial NIHSS were comparable between the groups. 100.0% of patients in the DTAS group vs 90.1% in the non DTAS received tPA (p = 0.264). EVT was performed on 85.0% of patients in the DTAS group vs 77.1% in the non DTAS group (p = 0.634). DTAS group had a faster alert to puncture time (108.00 min [94.75,124.75.] vs 150.50 min [121.25, 179.00], p< 0.001) and door to puncture time (37.00 min [25.50,62.75 vs 86.50 min [62.50,116.00], p< 0.001). The mean score on the uw‐mRS at 90 days was 0.626 ±0.367 in the DTAS group and 0.660 ±0.382 in the non DTAS group and after adjustment for age, baseline NIHSS, premorbid functional status, prior stroke/TIA and site, no significant difference was observed; (p = 0.54). In an unadjusted analysis, early neurologic recovery (72.7% vs 67.6%, (OR = 0.634, 95% CI [0.46,3.82]) and functional independence (50.0% vs 51.4%, p = 1.000) were comparable between DTAS and non DTAS patients. Patients in the DTAS group were less likely to receive general anesthesia (36.4% vs 71.2%, p = 0.004). Rates of recanalization (77.3% vs73,4%, p = 0.947) and post procedural PH‐2 hemorrhage (4.5% vs 0.9%, p = 0.746) were similar in the DTAS and non DTAS group respectively. Conclusions In tPA‐eligible LVO stroke patients, DTAS management resulted in shorter alert to puncture (42 minutes) and door to puncture times (50 minutes) with similar safety and clinical outcomes compared with non DTAS management. MSU DTAS represents an optimized pathway for LVO patients triaged and treated in the field.

Background: Few data exist on acute stroke treatment in patients with pre-existing disability (PD) since they are usually excluded from clinical trials. A recent trial of mobile stroke units (MSUs) demonstrated faster treatment and improved outcomes, and included PD patients. Aim: To determine outcomes with tissue plasminogen activator (tPA), and benefit of MSU versus management by emergency medical services (EMS), for PD patients. Methods: Primary outcomes were utility-weighted modified Rankin Scale (uw-mRS). Linear and logistic regression models compared outcomes in patients with versus without PD, and PD patients treated by MSU versus standard management by EMS. Time metrics, safety, quality of life, and health-care utilization were compared. Results: Of the 1047 tPA-eligible ischemic stroke patients, 254 were with PD (baseline mRS 2-5) and 793 were without PD (baseline mRS 0-1). Although PD patients had worse 90-day uw-mRS, higher mortality, more health-care utilization, and worse quality of life than non-disabled patients, 53% returned to at least their baseline mRS, those treated faster had better outcome, and there was no increased bleeding risk. Comparing PD patients treated by MSU versus EMS, 90-day uw-mRS was 0.42 versus 0.36 (p = 0.07) and 57% versus 46% returned to at least their baseline mRS. There was no interaction between disability status and MSU versus EMS group assignment (p = 0.67) for 90-day uw-mRS. Conclusion: PD did not prevent the benefit of faster treatment with tPA in the BEST-MSU study. Our data support inclusion of PD patients in the MSU management paradigm.

Background: Migraines have been associated with an increased risk of vascular disease and obstetric complications during pregnancy. Our study seeks to provide a consolidated examination of cerebrovascular and obstetric complications of migraines in pregnant women and to evaluate the role of concurrent comorbidities.Methods: We utilized the 2016-2020 Healthcare Cost and Utilization Project’s National Inpatient Sample (NIS) with the International Classification of Diseases, 10th Revision (ICD-10) diagnostic codes to compare pregnant patients with migraines to those without migraines. Multivariate regression was used to create a propensity score to examine the incidence of subtypes of stroke, while controlling for confounding variables.Results: 19,825,525 pregnant patients were evaluated; 219,175 (1.1%) had a concomitant diagnosis of migraine. Pregnant women with migraine were 10.5 times more likely to have ischemic stroke (OR 10.51 95% CI 4.55-24.29, p < 0.001), 45 times more likely to develop non-traumatic subarachnoid hemorrhage (OR 45.60 95% CI 11.23-185.10, p < 0.001), and 9.5 times more likely to develop intracerebral hemorrhage (OR 9.50, 95% CI 2.21-40.80, p < 0.001). Pregnant migraineurs were 1.4 times more likely to have preterm labor with (OR 1.34, 95% CI 1.25-1.43, p < 0.001) or without preterm delivery (OR 1.41, 95% CI 1.32-149, p < 0.001).Conclusions: When controlling for confounding factors, pregnant women with migraine are at a significantly increased risk for both ischemic and hemorrhagic stroke, as well as preterm labor, supporting theories on the role of cortical spreading depression and endovascular dysfunction in the etiology of migraines.Funding: None to declare. Declaration of Interest: None to declare.

The prehospital phase is a critical component of delivering high-quality acute stroke care. This topical review discusses the current state of prehospital acute stroke screening and transport, as well as new and emerging advances in prehospital diagnosis and treatment of acute stroke. Topics include prehospital stroke screening, stroke severity screening, emerging technologies to aid in the identification and diagnosis of acute stroke in the prehospital setting, prenotification of receiving emergency departments, decision support for destination determination, and the capabilities and opportunities for prehospital stroke treatment in mobile stroke units. Further evidence-based guideline development and implementation of new technologies are critical for ongoing improvements in prehospital stroke care.