Introduction: Early endovascular treatment (EVT) in patients with large vessel occlusions (LVO) is associated with better outcomes. Identifying and categorizing delays to EVT may reveal areas for improvement. Methods: We prospectively identified all patients who underwent EVT at our hospital between May 2022 - 2023. We determined eight steps in acute care: arrival, imaging, IR activation, ED release, arrival to IR, groin puncture, first pass, and recanalization. We classified patients as delayed if any interval exceeded their rolling six-month median. We created 12 categories and 36 subcategories of delays. We used t-test and odds ratios to compare intervals and outcomes between delayed and non-delayed patients. We analyzed subgroups based on causes of delay and location of presentation. Results: Out of 183 LVO patients who underwent EVT, 111 (61%) were delayed. There were no significant differences in age, gender, last known normal to arrival, NIHSS, thrombolytic use, or TICI scale. The delayed group had higher door to groin (99 min), door to device (126 min), and door to recanalization (159 min) compared to the non-delayed group (40, 65, 81 min; p < 0.001). The most common causes of delay were: general case complexity (20%), which was associated with higher door to imaging (59 min, p < 0.001) and imaging to IR activation (37 min, p = 0.03); after hours presentation (19%), which was associated with higher door to imaging (53 min, p = 0.02) and imaging to IR activation (36 min, p = 0.01); and procedural complexity (18%) which was associated with higher groin to device (34 min, p < 0.001) and device to recanalization (53 min, p < 0.001) when compared to other causes of delay. Between the delayed and non-delayed group, there was no significant difference in the length of stay, change in NIHSS at discharge, in-hospital mortality, disposition, or 90-day mRS. Subgroup analysis showed a trend towards higher mortality in delayed patients who presented after hours (OR 3.60 (CI) 0.92-14.10) or in-hospital (OR 2.41 (CI) 0.57-10.19). Conclusions: We determined seven intervals where delays can occur between arrival and recanalization of LVO patients. We created a system for categorizing delays that showed areas for improvement including after hours and in-hospital stroke evaluation.

Background: Neurologic patients transferred to an intensive care unit (ICU) have increased length of stays, mortality, and healthcare cost. There is limited data regarding incident transfers in stroke-specific cohorts. We sought to identify clinical features, transfer timing, and outcomes of patients admitted with ischemic stroke who required ICU escalation. Methods: We identified all patients age >18 admitted to our institution with a principle diagnosis of ischemic stroke between 2016 and 2019. We included patients requiring transfer to an ICU at any point in their hospitalization. We identified indications for transfer (IFT), time to ICU transfer (TTI), and outcomes at discharge and at 90-days post-discharge. We subdivided the IFT into neurologic and non-neurologic etiologies, and used chi-square testing and Kaplan-Meier curves with log-rank modeling to identify differences between patients with neurologic and non-neurologic transfer indications. Results: 3176 patients were admitted with a principle diagnosis of ischemic stroke across the four-year study period. 118 stroke patients (3.7%) underwent incident ICU transfer, 49 (41.5%) due to neurological causes and 69 (58.5%) due to non-neurological causes. The most common neurologic IFTs were cerebral edema (51.0%) and intracerebral hemorrhage (14.3%). The most common non-neurologic IFTs were respiratory decline (47.8%) and shock (21.7%). There were no differences in stroke characteristics (last known normal prior to arrival, baseline NIHSS, thrombolytic rates) between patients with neurologic vs. non-neurologic IFTs. Patients with neurologic IFTs had shorter mean TTI (2.45 vs. 4.80 days; p = 0.035) and were less likely to be discharged home compared to patients with non-neurologic IFTs (21.7% vs. 6.1%; p = 0.021). We corroborated differences in IFTs by adjusted log-rank comparisons on survival analysis. There were no significant difference in length of ICU stay (4.66 vs. 4.83 days) or total length of stay (12.37 vs 16.75 days). Conclusions: Most ischemic stroke patients’ incident ICU transfers occur in the first 48 hours, highlighting the need for early vigilance. Neurologic and non-neurologic etiologies for IFT may contribute to the patients’ disposition outcome.

Introduction Spontaneous simultaneous bilateral basalganglia hemorrhage is an exceedingly rare condition with significant morbidity and mortality. Hypertension is the most common underlying etiology followed by intoxication and metabolic causes1. Methods Here we describe a 39‐year‐old woman with a spontaneous simultaneous bilateral putaminal hemorrhages believed to be secondary to amphetamine (Adderall) use and undiagnosed hypertension. Results A 39‐year‐old right‐handed woman with history of attention‐deficit/hyperactivity disorder (ADHD) on dextroamphetamine‐amphetamine (Adderall), white coat hypertension and prior gestational hypertension was brought to the emergency department due to sudden‐onset left hemiparesis, left foot numbness, gait instability, and an abnormal sensation in her right ear. On arrival, blood pressure was 239/139 mmHg. Patient was noted to be somewhat drowsybut was consistently regarding,able to respond, and had anosognosia, hypophonia, a right gaze preference, mild dysarthria, left arm and leg hypotonia, left hemiparesis and hypoesthesia involving face, arm and leg and brisk reflexes on the left side.Head CT revelated bilateral putaminal hemorrhages measuring 10mL on the right and 3mL on the left,with no intraventricular hemorrhage and minimal right‐to‐left midline shift.Patient was admitted to the neuro ICU and treated with a nicardipine infusion. CTA/MRI/MRV/MRA and catheter angiography revealed no underlying structural pathology. Furthermore, patient had a normal platelet count and coagulation profile. Urine drug screen was positive for amphetamines, and serum metanephrines (0.59 nmol/L) and normetanephrines (1.2nmol/L) were elevated in the setting ofAdderall use. Nicardipine infusion was discontinued on day one and she was started on carvedilol 12 mg bid and amlodipine 5mg daily. Adderall was discontinued and patient was counseled on avoiding stimulant medications use. At time of discharge her dysarthria had resolved but her left hemiplegia remained unchanged. She was discharged on day 5 of hospital stay to an inpatient rehabilitation facility. She was started on fluoxetine 20 mg daily for motor recovery at the rehabilitation facility. At her two months follow‐up visit, she was noted to have significant improvement in her left‐sided strength, hypoesthesia and left facial droop but had developed left arm and leg spasticity. She was started on a trial of dry needling with physical therapy prior to consideration of anti‐spasmodic medications or Botox injections. At her office visit, her blood pressure had been well controlled on lisinopril 10 mg and amlodipine 10 mg daily. Conclusions Overall, this case report highlights that amphetamine (Adderall) use is a potential cause of spontaneoussimultaneousbilateralbasalgangliahemorrhage.

A 74-year-old woman with mild Alzheimer disease joined a clinical trial of anti-amyloid-beta therapy. Three weeks after receiving remternetug, a N3pH-A beta monoclonal antibody, a scheduled brain MRI showed new periventricular and subcortical FLAIR hyperintensities (Figure, A) suggestive of mild amyloid-related imaging abnormalities (ARIA).1,2 Two weeks later, she was hospitalized for rapid cognitive and functional decline. Her admission examination was notable for severe disorientation, inattention, and global aphasia. Repeat MRI showed diffuse and confluent FLAIR hyperintensities consistent with progression to severe ARIA-edema/effusion (ARIA-E), but no hemosiderosis/microhemorrhages (ARIA-H) (Figure, B). She was treated with steroids and continued to have a gradual improvement in her cognition and language. A follow-up MRI 6 weeks later showed a marked reduction in FLAIR hyperintensities (Figure, C). In clinical trials, ARIA-E has often been observed to improve within 3-4 months.2 Early suspicion of ARIAs is essential for identifying and managing this adverse effect of anti-amyloid-beta therapy.

Introduction: The need for recruitment of neurologists from underrepresented communities has been emphasized to maintain workforce diversity in academic neurology practice. The objective of the study is to describe the racial and ethnic diversity of neurology residents (NR) pursuing vascular neurology (VN) fellowship. Methods: Cross-sectional study of race/ethnicity of NR and VN fellows using published Graduate Medical Education (GME) census reports from 2006, when race/ethnicity data were first included, to 2018. Proportions were compared using chi-square test. Non-Accreditation Council of GME fellowship data was unavailable for analysis. Results: A total of 24450 NR were included in the sample of which 12718 (52%) were White, 993 (4.1%) Black, 1973(8%) Hispanics, 8232(33%) Asians. Of 910 NR who pursued VN fellowship, 413 (49.2%, SD 12.5%) were White, 27 Black (3%, SD 2.1%), 333 Asians (34%, SD 10.7%) and 78 Hispanics (10%, SD 5%). When comparing periods 2006-10 vs 2016-18, the proportion of White NR has increased by 2% (p=0.014), however, the increase in Black NR is 0.1% and not statistically significant. The proportion of Asian VN fellows significantly increased to 43% in 2016-20 compared to 24% over the entire period (p=0.039). Conclusion: There are racial disparities among NR and fellowship trainees. Even though there is diversity among VN fellows, continued efforts should be made to promote underrepresented ethnic groups.

The objective of the study was to determine if involvement of basal ganglia (BG) or insular ribbon (IR) on CT perfusion (CTP) core or CT Alberta Stroke Program Early CT Score (CT-ASPECTS) was associated with higher incidence of post-thrombectomy intracranial hemorrhage (ICH) in patients with large vessel occlusion stroke (LVOs) who had favorable CT perfusion scan (CTP) at presentation.