Background/Objective: Active malignancy increases the risk of ischemic stroke through multiple mechanisms, including cancer-associated hypercoagulability which has led to debate regarding secondary stroke prevention strategies. We aimed to further understand and model antithrombotic decision making and recurrent stroke within this population. Design: Single-center, retrospective cohort study from a single tertiary academic cancer center, of patients with active malignancy and ischemic stroke from 2015-2021. Patients with primary hemorrhage, clear indication for antiplatelet or anticoagulant, carotid intervention, or death within 30 days were excluded. Regression identified independent predictors of antithrombotic selection. Results: 1909 patients were reviewed with 306 patients included who met inclusion criteria. A total of 237 patients were prescribed antiplatelet agents and 69 were prescribed anticoagulant after stroke. The anticoagulant cohort had a higher frequency of Black race (47.8% vs. 32.9%), lung cancer (37.7% vs. 21.5%), pancreatic cancer (18.8% vs. 5.1%), and metastatic disease (88.4% vs. 49.4%). Regression analysis found metastatic disease (OR 8.39, 95% CI 3.86-18.25, p<0.001) and simultaneous anterior and posterior circulation stroke (OR 5.77, 95% CI 3.23-10.31, p<0.001) independently predicted anticoagulant use. Hypertension, hyperlipidemia, and unilateral stroke independently predicted antiplatelet use. Within 180 days, recurrent ischemic stroke occurred in 17.4% on anticoagulation vs. 13.9% on antiplatelet therapy, and major hemorrhage in 13.0% vs. 5.1%, respectively. Summary: In a single center cohort of 306 patients with active malignancy and new ischemic stroke, metastatic disease and multi-territory infarction were found to be independent predictors of anticoagulant use for secondary prevention, while traditional vascular risk factors and unilateral stroke predicted antiplatelet use for secondary prevention. Recurrent stroke and major bleeding were more common with use of anticoagulation within 180 days, though patients often had more advanced disease. Future propensity score–matched analyses are planned to further compare recurrent stroke rates and adverse events between groups. These findings further highlight the need for prospective studies to guide secondary prevention in cancer-associated stroke.

Cranial radiation is a cornerstone in management of glioma though is associated with increased stroke risk. Hyperlipidemia has previously been found to be associated with increased stroke risk in this population. This study aimed to evaluate whether statin use is associated with reduced stroke risk in patients with glioma and hyperlipidemia who underwent cranial radiation. We conducted a retrospective study of adult patients with glioma and hyperlipidemia who received cranial radiation between 2005 and 2021. Data were collected from time of cranial radiation until last follow-up. Patients diagnosed with hyperlipidemia through review of medical records at time of stroke were included in the analysis. Cox-proportional hazards modeling was performed to evaluate incident stroke with death as a competing event to evaluate the impact of statin exposure on stroke. In a cohort of 297 patients that received cranial radiation and had hyperlipidemia, 65 (21.9

BACKGROUND:Patients with glioma undergoing radiation therapy have been found to have elevated cerebrovascular risk. Bevacizumab, commonly used in this population for radiation necrosis, tumor recurrence, and cerebral edema, has prothrombotic and hemorrhagic effects, though its influence on stroke presentation in this population remains poorly characterized. METHODS:We performed a retrospective analysis of patients with glioma who developed stroke following cranial radiation therapy within the PRoGREss institutional registry. Bevacizumab exposure was ascertained at the time of the stroke event. Stroke subtype, severity, antithrombotic use, and discharge functional status were compared between patients with and without concurrent bevacizumab exposure. RESULTS:Of 910 registry patients, 91 (10.0%) developed stroke following cranial radiation. At the time of stroke, 59 (64.8%) were receiving bevacizumab and 32 (35.2%) were not. Intraparenchymal hemorrhage occurred numerically more often in bevacizumab-exposed patients (32.2% vs. 15.6%), though this difference was not statistically significant (Fisher's Exact p = 0.13). Among patients with IPH, concurrent therapeutic anticoagulation was substantially more prevalent in the bevacizumab-exposed group (31.6% vs. 0.0%, Fisher's Exact p = 0.28). CONCLUSIONS:In this exploratory cohort of 91 patients with stroke after cranial radiation, bevacizumab exposure at the time of stroke was not independently associated with intraparenchymal hemorrhage. The observed numerical difference was not statistically significant and was substantially confounded by higher rates of concurrent therapeutic anticoagulation in the bevacizumab-exposed group. The primary hypothesis generated by these data is that concurrent bevacizumab and therapeutic anticoagulation may together confer meaningful hemorrhagic risk in this population, warranting dedicated prospective investigation.

BACKGROUND: Stroke is a possible complication after bioprosthetic aortic valve replacement (AVR) for severe aortic stenosis (AS), impacting morbidity and mortality. Accurate estimates of the proportion of individuals who experience stroke within and beyond the periprocedural period after transcatheter AVR (TAVR), surgical AVR, and valve-in-valve (ViV) replacement are essential for management and prognostication. The objective was to determine the proportion of adults aged >18 who experienced an ischemic stroke after bioprosthetic AVR for AS METHODS: A systematic search of MEDLINE, Embase, and Web of Science was conducted from database inception through March 2024. Studies reporting on stroke rates at least 90 days after bioprosthetic AVR for severe AS, including VIV procedures, and meeting predefined eligibility criteria were included. The pooled proportion of individuals experiencing a stroke was estimated for TAVR and ViV procedures, whereas comparative analyses between TAVR and surgical AVR were performed using mixed-effects models in studies directly comparing both procedures. RESULTS: Twenty-seven studies were included in the native AS treatment cohort, and 5 in the ViV subanalysis. In native AS, the pooled 30-day proportion of individuals who had a stroke after TAVR was 3.0% (95% CI, 2.5-3.9), with different studies reporting major and minor stroke proportions of 1.7% each. At 1 year, all stroke proportion was 5.0% (95% CI, 4.0-6.0), major stroke was 3.0%, and minor stroke was 2.0%. Comparative analysis demonstrated that TAVR was associated with significantly lower odds of all stroke at 30 days compared with surgical AVR (odds ratio, 0.73 [95% CI, 0.57-0.93]). No significant difference in the proportions of individuals who had a stroke was observed in TAVR versus surgical AVR at 1, 2, or 5 years. In the ViV cohort, the pooled 30-day and 1-year all stroke proportion after ViV was 2.0% (95% CI, 1.0-3.0) and 3.0% (95% CI, 2.0-6.0), respectively. CONCLUSIONS: This meta-analysis provides updated estimates of stroke after bioprosthetic AVR for AS, capturing risk beyond the early periprocedural period. Future studies should investigate the causes of long-term stroke post-AVR, the effects of different antithrombotic therapies on the risk of stroke, as well as the potential impact of these procedures on short and long-term cognitive function.

BACKGROUND:The best revascularization strategy for acute ischemic stroke from isolated vertebral artery occlusion remains unclear. METHODS:This retrospective, international, multicenter cohort study included patients from 30 comprehensive stroke centers across Europe (n=23), North America (n=5), and Asia (n=2) between 2016 and 2022. Eligible patients presented with acute ischemic stroke within 24 hours of last seen well and had imaging-confirmed isolated vertebral artery occlusion. Two treatment comparisons were analyzed: intravenous thrombolysis (IVT)-only versus conservative treatment (Cx), and endovascular treatment (EVT)±IVT versus medical management (Cx and IVT). The primary outcome was the shift in 3-month modified Rankin Scale (mRS) score; secondary outcomes included early neurological improvement (24-hour-delta National Institutes of Health Stroke Scale score), recanalization, early neurological deterioration of ischemic origin, symptomatic intracerebral hemorrhage, and 3-month mortality. Analyses were adjusted using inverse probability of treatment weighting (IPTW). RESULTS:Among 494 patients, 143 (29%) received Cx, 218 (44%) IVT-only, and 133 (27%) EVT±IVT. Compared with Cx, IVT-only showed similar 3-month mRS score (IPTW-adjusted odds ratio [aOR] mRS shift score, 1.32 [95% CI, 0.80-2.18]), greater early neurological improvement (IPTW-adjusted-β coefficient, -1 [95% CI, -2.05 to 0.05]), and higher recanalization rates (IPTW-aOR, 4.33 [95% CI, 1.36-13.78]). Compared with MM (=IVT+Cx), EVT±IVT was associated with an unfavorable mRS shift score (IPTW-aOR mRS shift score, 0.51 [95% CI, 0.35-0.74]), higher early neurological deterioration of ischemic origin (IPTW-aOR, 9.06 [95% CI, 2.86-28.67]), and symptomatic intracerebral hemorrhage (IPTW-aOR, 6.05 [95% CI, 1.14-32.1]) though recanalization was over 4-fold higher (OR, 4.64 [95% CI, 1.90-11.33]). Patients with National Institutes of Health Stroke Scale score ≥10 showed point estimates favoring EVT+IVT (Pinteraction=0.025). CONCLUSIONS:IVT-only appeared safe and was associated with better early recovery and recanalization. EVT±IVT showed overall worse outcomes, potentially due to increased early neurological deterioration of ischemic origin and symptomatic intracerebral hemorrhage rates, but may confer benefit in moderate-to-severe strokes, warranting prospective trials in symptomatic isolated vertebral artery occlusion.

INTRODUCTION:Post-stroke dysphagia (PSD) is a common complication following acute ischemic stroke (AIS). Predicting the recovery of swallow function remains challenging. The Predictive Swallow Score (PRESS) model, derived and validated in a Swiss cohort, sought to predict the recovery of PSD after AIS. We aimed to validate the PRESS model in a US-cohort, conducting a two-center retrospective review of 149 patients with AIS and functional oral intake scale (FOIS) ≤ 4. METHODS:We collected the predictors of recovery of PSD according to PRESS (age, NIH Stroke Scale (NIHSS), any2 score, stroke location, FOIS score), with a primary outcome of impaired swallow at day 7 (FOIS ≤ 4). Model validation was completed using the Hosmer-Lemeshow (HL) test, calibration plots, and AUC analysis. RESULTS:Median (IQR) age was 74 (61-86); 53% were female. Median (Q1-Q3) NIHSS at presentation was 14 (7-20). HL test demonstrated that the PRESS model did not fit the validation data (p < 0.00001, x2=48.343, df=5), and the calibration curve analysis (intercept = -0.80 (95% CI: -1.21 to -0.38), slope = 0.60 (95% CI: 0.37 to 0.82)) also demonstrated a poor calibration of the model. Area under the curve analyses demonstrated a C statistic of 0.75 (95% CI 0.67-0.82), indicating suboptimal model discrimination in predicting the recovery of swallow 7 days following AIS. In particular, the model overpredicted dysphagia severity at day-7 in patients with higher PRESS scores and more severe strokes. CONCLUSION:Further validation of the PRESS score in prospective cohorts is warranted. The suboptimal model performance could be attributed to temporal advances in stroke care, as the original PRESS cohort was derived between 2011 and 2014. Geographic variability in acute stroke care practice could also be a factor, as the PRESS score was derived solely from a European cohort. This study, however, is limited by its retrospective design and a lack of generalizability.

The prevalence of Alzheimer’s Disease (AD) is increasing worldwide, with more emergency providers and neurologists expecting to encounter these patients. The paradigm of management of AD is expected to change given the recent approval of anti-amyloid therapies (AATs). The most concerning complication of these therapies is amyloid-related imaging abnormalities (ARIA), which can lead to an increased risk of cerebrovascular complications. Given a growing population of patients with AD and growing use of AATs, providers must be prepared to manage patients at risk of cerebrovascular disease and those presenting with neurologic deficits. This subpopulation warrants a unique approach given the risk of ischemic stroke and the associated risk of hemorrhage present in the use of AATs. In this narrative review, we present and propose management considerations in the acute stroke setting and patients at risk of cerebrovascular disease, including patients with indications for anticoagulation, to most appropriately manage this special population. Future cross-disciplinary collaboration and use of registry data will be essential to narrow management approaches and develop safety data.

Post-stroke dysphagia (PSD) is a common complication following stroke. Predicting the recovery from PSD remains a major challenge. The Predictive Swallow Score (PRESS) model, derived and validated in Switzerland, sought to predict recovery from PSD after an acute ischemic stroke (AIS). We sought to perform the first external validation of the PRESS model. A two-center retrospective cohort study of 149 dysphagic patients with functional oral intake scale (FOIS) ≤4 following AIS was conducted. Demographic data and clinical co-variates (age, NIHSS, ANY2 score, frontal opercular stroke, FOIS) were collected to predict the recovery from dysphagia at post-stroke day 7. The primary outcome was impaired swallow at day 7 (FOIS ≤ 4). The mean age was 72.1 years (±16.0) and 79 (53%) were females. Median (Q1-Q3) NIHSS at presentation was 14 (7-20), ANY2 score 5 (3-6), FOIS at presentation 1 (1-4). 66 patients had frontal-opercular involvement of stroke. Median FOIS at 7-day follow-up from stroke was 4 (1-5), with 71 (44%) being classified as impaired. The Hosmer-Lemeshow test rejected the null hypothesis that the PRESS model was a good fit to the validation data (p=<0.0001, x 2 =55.735, df=5). Calibration curve analysis revealed that the PRESS model overpredicted the likelihood of persistent dysphagia. The C-statistic of the PRESS model on the validation cohort was 0.74 (95% CI: 0.65-0.81). In a secondary analysis, impaired subjects (FOIS ≤ 4) at day-7 had a higher median (Q1-Q3) admission NIHSS (15 [7.5-21] vs 12 [6-17], p=0.02), ANY2 score (6 [4-6] vs 4 [3-5], p<0.0001), PRESS score (8 [6-9] vs 5 [2-8], p<0.00001), and higher frequency of frontal opercular stroke location (64% vs 46%, p=0.03). However, age (p=0.17) and sex (p=0.07) were associated with persistent dysphagia at day 7. This first external validation study of the PRESS model did not support its use as a tool to predict recovery from PSD, potentially owing to regional variation in the predictive power of certain co-variates such as stroke severity, stroke location, and age. The study is limited by its retrospective design. A larger prospective cohort study is needed to evaluate the PRESS model prior to clinical adoption.

BACKGROUND AND OBJECTIVES:Radiation therapy is the mainstay of therapy for patients with glioma. While this treatment modality can improve survival, treatment-related complications may include radiation-induced vasculopathy and increased risk of stroke. We aimed to evaluate the stroke frequency, associated risk factors, and outcomes after cranial radiation therapy in patients with glioma. METHODS:This is a retrospective cohort study at a single tertiary academic brain tumor center involving patients diagnosed with gliomas between 2005 and 2021 who received cranial radiation therapy. Data were collected from the time of cranial radiation therapy until last follow-up. Logistic regression analyses were used to evaluate the association of clinical and demographic variables with all-cause, ischemic, and hemorrhagic strokes. RESULTS:In a retrospective cohort of 930 patients, 910 received radiation therapy (mean age 53.8 years; 40% women) and were included in the final analysis. A total of 91 patients (10.0%) were diagnosed with stroke (73.6% ischemic; 15.4% with recurrent strokes). The median time to diagnosis of stroke after onset of radiation therapy was 652 days with median time to recurrent stroke of 102 days. In a univariable model, Black race (odds ratio [OR] 3.83, 95% CI 1.94-7.56), radiation necrosis (OR 4.62, 95% CI 2.02-10.55), hypertension (OR 1.93, 95% CI 1.23-3.01), hyperlipidemia (OR 5.93, 95% CI 3.61-9.57), and diabetes mellitus (OR 2.25, 95% CI 1.28-3.95) were associated with higher odds of all-cause stroke. In multivariable analysis, Black race (OR 3.41, 95% CI 1.59-7.33), radiation necrosis (OR 6.42, 95% CI 2.45-16.79), and hyperlipidemia (OR 6.42, 95% CI 3.91-10.57) were significantly associated with increased odds of all-cause stroke. Radiation necrosis and hyperlipidemia were associated with increased odds of ischemic stroke. Black race, hyperlipidemia, and younger age were associated with increased odds of hemorrhagic stroke. Compared with ischemic strokes, hemorrhagic strokes were associated with higher poststroke disability. DISCUSSION:In a large, retrospective cohort of adult patients with glioma treated with cranial radiation therapy, 1 in 10 patients were subsequently diagnosed with stroke with 15.4% suffering recurrent strokes. Factors associated with increased odds of stroke included Black race, radiation necrosis, and hyperlipidemia and should be validated in future prospective cohorts. Study limitations include the retrospective design, incomplete stroke workups, and lack of molecular diagnostics.

Objectives:To discuss utility of using DWI-FLAIR mismatch in select patients not included in the original WAKE-UP trial for administration of IV thrombolytics. Methods:We identified a female over 100 years old who presented with stroke symptoms upon waking up. This case is selected due to its unique management. Relevant clinical data was collected through a review of the patient's medical records. All data were anonymized to ensure confidentiality. Results:A 102-year-old female with a complex past medical history of atrial fibrillation, not on anticoagulation presented with a National Institutes of Health Stroke Scale (NIHSS) of 23. Stroke symptoms were present upon awakening. Noncontrast computed tomography (CT) of the head was negative for hemorrhage or early ischemic changes. CT angiography (CTA) of the head and neck was notable for a distal right M2 occlusion. A hyperacute magnetic resonance imaging (MRI) of the brain was pursued to determine potential eligibility for intravenous thrombolysis (IVT). Patient consented to IVT. NIHSS improved to 13. She was eventually discharged to a skilled nursing facility. Discussion:We aimed to highlight the oldest known case of IV thrombolysis in this patient presenting with a stroke upon awakening. This is to emphasize possible benefit in cases not included in the original WAKE-UP trial.

Background/Objectives: Perioperative stroke is a significant cause of morbidity and mortality in patients undergoing cardiac, vascular, and neurosurgical procedures. We assessed the rate, characteristics, risk factors and survival outcomes of perioperative stroke following surgical resection of glioma. Design: This is a retrospective chart review of a single quaternary care center of patients with glioma between 2005-2021 who underwent resection. Stroke within 30 days of surgical resection was identified based on the radiology read of MRI brain for ischemic stroke and CT brain for hemorrhagic stroke that was obtained as part of clinical care. This was then confirmed retrospectively by a neurologist who reviewed imaging and medical records, excluding expected post-operative changes. Descriptive analysis and logistic regression were conducted. Overall survival was estimated with Kaplan-Meier methods from the date of surgery to death and compared with the log rank test. Results: Out of 738 patients who underwent surgical resection of their glioma and underwent brain MRI or CT head, 20 (2.71%) had radiographic evidence of strokes, with the mean (SD) time from surgery to stroke 5.4 (16.2) days. Of these, 13 (65%) had ischemic strokes, 7 (35%) had hemorrhagic strokes. Out of all perioperative strokes, 9 (45%) were symptomatic (total incidence of 1.2%), and 11 (55%) were asymptomatic. Patients who had a stroke were older [mean (SD); 60.4 (13.7) vs. 52.8 (15.0) years; p=0.026], had a higher rate of atrial fibrillation (p= 0.002), and had comorbid hyperlipidemia (p=0.039) and hypertension (p=0.047). Descriptive analysis of this cohort is summarized in Table 1. Older age, carrying a diagnosis of atrial fibrillation, and having hyperlipidemia were associated with higher odds of having a perioperative stroke (Table 2). In an attempt to generate a multivariate logistic model, stepwise selection yielded no significant results likely due to the low number of strokes in this cohort. The median survival for patients with stroke was 24.6 months (95% CI:21.8-32.1), which was lower than for patients who did not suffer a stroke (29.3 months, 95% CI: 25.6-32.9) (p=0.052). Conclusion: Older age, atrial fibrillation, hyperlipidemia, and hypertension were associated with perioperative stroke risk after glioma resection. Future studies should evaluate underlying mechanisms and stroke etiologies to better identify high risk patients.

We present a case report of a 38-year-old woman who presented to the hospital with acute onset high amplitude, non-rhythmic, hyperkinetic movements of the right upper extremity, abnormal sensation of the right upper extremity from the elbow to the hand, and the inability to recognize her hand without visual input. This case discusses the differential diagnoses of acute hyperkinetic movement disorders and concurrent alien-limb in a patient presenting within the time window for vascular intervention. Readers are led through the reasoning behind acute interventional decision-making in a patient with a rare presentation. Workup reveals the eventual diagnosis.

A 77-year-old woman with a medical history of amnestic mild cognitive impairment on lecanemab presented to the hospital with new onset shortness of breath. ECG revealed new diagnosis of atrial fibrillation with rapid ventricular response. Considering the patient's risk factors with a CHA2DS2-VASc score of 6, the patient would warrant use of anticoagulation, with the caveat that this is currently not recommended with use of lecanemab. In this case, we describe the management dilemma posed by new diagnosis of atrial fibrillation using anti-amyloid immunotherapies and suggest possible solutions in this unique population.

Acute aortic dissection is considered a contraindication to the use of intravenous thrombolysis in patients presenting with acute ischaemic stroke, but less has been described about previously repaired dissections. We present a case of a woman in her 50s presenting with acute left hemiparesis with a known history of aortic dissection within the thrombolysis window. After multidisciplinary discussion with cardiothoracic surgery and discussion with the patient, she was treated with intravenous thrombolysis without complication. In patients with previously repaired aortic dissection without evidence of redissection, intravenous thrombolysis can be considered.

Stroke is a multifactorial vascular disease and remains a leading cause of disability in the United States. Strokes can be ischemic or hemorrhagic in nature and secondary to arterial or venous disease, making determining the etiology and secondary prevention strategy important for preservation of the injured brain, prevention of recurrent strokes, and in the maintenance of good functional outcomes for patients impacted by stroke. In this narrative review, we provide a synopsis of the available medical evidence surround selection, timing, and choice of therapy, including utilization of left atrial appendage closure, in patients with ischemic, hemorrhagic or venous stroke.

Cancer and stroke are leading causes of global disability and mortality. With improvements in cancer-associated mortality and advancements in treatment of active malignancy, it is more common to encounter patients with ischemic stroke and active malignancy. Evidence suggests that cancer-associated ischemic stroke is a unique subtype of stroke; however, there is limited guidance when considering diagnostic workup, secondary prevention, rehabilitation, and future directions within this population. In this narrative review, we aim to describe the epidemiology, pathophysiological mechanisms, management, and future directions regarding understanding of cancer-associated ischemic stroke.

Aneurysmal subarachnoid hemorrhage (aSAH) is a devastating neurologic disease with high mortality and disability. There have been global improvements in survival, which has contributed to the prevalence of patients living with long-term sequelae related to this disease. The focus of active research has traditionally centered on acute treatment to reduce mortality, but now there is a great need to study the course of short- and long-term recovery in these patients. In this narrative review, we aim to describe the core pillars in the preservation of cerebral function, prevention of complications, the recent literature studying neuroplasticity, and future directions for research to enhance recovery outcomes following aSAH.

To compare the characteristics, risk factors and stroke types in patients who suffered strokes after radiation therapy for primary brain gliomas based on bevacizumab (Avastin) use at the time of their stroke.