This randomized clinical trial investigates whether recombinant activated coagulation factor VII reduces hemorrhage expansion among patients with spot sign-positive intracerebral hemorrhage (ICH). Question For patients presenting to the emergency department with an acute intracerebral hemorrhage (ICH) and a spot sign on computed tomography angiography, a marker of hemorrhage expansion, does recombinant activated coagulation factor VII (rFVIIa) reduce hematoma expansion more than placebo? Findings In this pooled analysis including 69 patients from randomized clinical trials targeting patients with spot sign-positive ICH, rFVIIa did not significantly reduce hemorrhage expansion when administered up to 6.5 hours from stroke onset, although nearly all patients were treated more than 2 hours after stroke onset. Meaning These data do not support the clinical use of rFVIIa in patients with spot sign-positive ICH, and future trials to limit ICH expansion should test an earlier treatment window. Importance Intracerebral hemorrhage (ICH) is a devastating stroke type that lacks effective treatments. An imaging biomarker of ICH expansion-the computed tomography (CT) angiography spot sign-may identify a subgroup that could benefit from hemostatic therapy. Objective To investigate whether recombinant activated coagulation factor VII (rFVIIa) reduces hemorrhage expansion among patients with spot sign-positive ICH. Design, Setting, and Participants In parallel investigator-initiated, multicenter, double-blind, placebo-controlled randomized clinical trials in Canada ("Spot Sign" Selection of Intracerebral Hemorrhage to Guide Hemostatic Therapy [SPOTLIGHT]) and the United States (The Spot Sign for Predicting and Treating ICH Growth Study [STOP-IT]) with harmonized protocols and a preplanned individual patient-level pooled analysis, patients presenting to the emergency department with an acute primary spontaneous ICH and a spot sign on CT angiography were recruited. Data were collected from November 2010 to May 2016. Data were analyzed from November 2016 to May 2017. Interventions Eligible patients were randomly assigned 80 mu g/kg of intravenous rFVIIa or placebo as soon as possible within 6.5 hours of stroke onset. Main Outcomes and Measures Head CT at 24 hours assessed parenchymal ICH volume expansion from baseline (primary outcome) and total (ie, parenchymal plus intraventricular) hemorrhage volume expansion (secondary outcome). The pooled analysis compared hemorrhage expansion between groups by analyzing 24-hour volumes in a linear regression model adjusted for baseline volumes, time from stroke onset to treatment, and trial. Results Of the 69 included patients, 35 (51%) were male, and the median (interquartile range [IQR]) age was 70 (59-80) years. Baseline median (IQR) ICH volumes were 16.3 (9.6-39.2) mL in the rFVIIa group and 20.4 (8.6-32.6) mL in the placebo group. Median (IQR) time from CT to treatment was 71 (57-96) minutes, and the median (IQR) time from stroke onset to treatment was 178 (138-197) minutes. The median (IQR) increase in ICH volume from baseline to 24 hours was small in both the rFVIIa group (2.5 [0-10.2] mL) and placebo group (2.6 [0-6.6] mL). After adjustment, there was no difference between groups on measures of ICH or total hemorrhage expansion. At 90 days, 9 of 30 patients in the rFVIIa group and 13 of 34 in the placebo group had died or were severely disabled (P = .60). Conclusions and Relevance Among patients with spot sign-positive ICH treated a median of about 3 hours from stroke onset, rFVIIa did not significantly improve radiographic or clinical outcomes.

Background and Purpose-A large number of patients with symptoms of acute cerebral ischemia are stroke mimics (SMs). In this study, we sought to develop a scoring system (FABS) for screening and stratifying SM from acute cerebral ischemia and to identify patients who may require magnetic resonance imaging to confirm or refute a diagnosis of stroke in the emergency setting.Methods-We designed a scoring system: FABS (6 variables with 1 point for each variable present): absence of Facial droop, negative history of Atrial fibrillation, Age <50 years, systolic Blood pressure <150 mmHg at presentation, history of Seizures, and isolated Sensory symptoms without weakness at presentation. We evaluated consecutive patients with symptoms of acute cerebral ischemia and a negative head computed tomography for any acute finding within 4.5 hours after symptom onset in 2 tertiary care stroke centers for validation of FABS.Results-A total of 784 patients (41% SMs) were evaluated. Receiver operating characteristic curve (C statistic, 0.95; 95% confidence interval [CI], 0.93-0.98) indicated that FABS3 could identify patients with SM with 90% sensitivity (95% CI, 86%-93%) and 91% specificity (95% CI, 88%-93%). The negative predictive value and positive predictive value were 93% (95% CI, 90%-95%) and 87% (95% CI, 83%-91%), respectively.Conclusions-FABS seems to be reliable in stratifying SM from acute cerebral ischemia cases among patients in whom the head computed tomography was negative for any acute findings. It can help clinicians consider advanced imaging for further diagnosis.

Objective: To evaluate mismatch imaging as a predictor of outcome in patients treated with IV-rtPA < 3 hours. Background: Mismatch imaging predicts outcome with IV-rtPA and/or endovascular treatment beyond 3 hours. We evaluated its predictive value within the 3 hour window. Methods: After IRB approval, we retrospectively reviewed our data for patients treated solely with IV-rtPA within 3 hours. Treatment selection was in accordance with standard criteria. Our protocol included CTA and CTP (GE lightspeed VCT 64 slice, Perfusion 4), which were used for interventional decisions post IV-rtPA. Mismatch was defined as a MTT-CTV size difference greater than 30[percnt], determined rapidly with a free-hand "ROI" tool. We computed the percentage of each MTT-CTV combination associated with mRS=0-1 and ascertained strength of the association with Chi square analysis. Results: There were 98 patients with mean admission NIHSS=7.7. Listed in descending order of favorable outcome, the percentage of all patients, admission mean NIHSS, NIHSS change, and the percentage of patients with discharge mRS=0-1 for each MTT-CTV combination are: "MTT-CTV both normal": 36.7[percnt], 5.5, -3.8, 69.4[percnt]. "Mismatch": 15.3[percnt], 9.1, -6.7, 40[percnt]. "Infinite mismatch" (MTT abnormal, CTV normal): 35.7[percnt], 7.9, -4.8, 40[percnt]. "Match" (both abnormal): 12.2[percnt], 12, -1.75, 0[percnt]. For each MTT-CTV combination, Chi square test was significant at p<.001 for mRS=0-1. MRI revealed lacunar or small embolic infarcts in patients with normal MTT-CTV. There were no deaths or hemorrhages. Our results are fundamentally the same as those published for patients studied beyond 3 hours. Conclusion: Mismatch imaging within the 3 hour window produces results that are intuitively sensible and clinically consistent with those found beyond 3 hours. This rapid, simplified methodology has broad applicability.

Objective: To evaluate discordant results between TCD and TEE shunt studies. Background: We observed greater yield with TCD than TEE and sought an explanation. Methods: With IRB approval, we reviewed results of 138 stroke and TIA patients who were studied within 24 hours of each other. TCD was interpreted by two physicians and performed per refinement of a literature-based performance protocol (PP): 2 MHz transducer; target middle cerebral artery; contrast= agitated 9.5 cc saline + 0.5 cc air; injected antecubitally via 18 gauge access before and after valsalva; supine and right lateral decubitus (twice each); recording for 20 seconds; positive: > 1 bubble artifact on > 1 injection. TEE was performed by 5 cardiologists with omniplane multihertz probe and mechanical index of 0.7; conscious sedation; left anterolateral semi-upright position; long and short 4 chamber views. There was no TEE performance protocol (PP) for size/location of IV line, contrast preparation, timing and number of injections, use of valsalva, recording time, criteria for positivity. Results:. Sensitivities of TCD and TEE were 93.8[percnt] and 53.1[percnt]. Of 34 + on TCD, 12 were + on TEE (0.35); of 18 + on TEE, 17 were + on TCD (0.94). Overall agreement: 29/52=0.56. TCD operator agreement with TEE was 64.7[percnt] and 64.1[percnt]. TEE operator agreement with TCD varied from 50[percnt] to 73.7[percnt]. The lower yield of TEE and low interstudy agreement likely reflect the lack of PP for TEE. We found one published consensus PP for shunt detection w/ TCD and none published for TEE, or at websites ACC, AIUM, ASE. Conclusions: The discordant results between TCD and TEE reflect lack of PP resulting in performance differences between operators of TEE. False negatives may exist in community use of TEE. Consensus PP and accreditation criteria will improve quality for both TCD and TEE.

Objectives: To determine whether vascular and demographic factors predict worsening disability up to 8 years after lacunar stroke. Methods: SPS3 (Secondary Prevention of Small Subcortical Strokes) was a clinical trial in lacunar stroke patients with annual assessment of disability using the Older Americans Resources and Survey instrumental activities of daily living (IADL) scale (range 0–14). Generalized estimating equations modeled the likelihood of disability (IADL <14) over time, adjusting for demographics, medical risk factors, cognition, mood, stroke location, and geographic region in univariate and multivariable models. IADL assessments after recurrent stroke were censored. We stratified by study region and age quartile. Results: Among 2,820 participants, mean age was 63.4 years (SD 10.8), 63% were male, 36% had diabetes, 90% hypertension, and 10% prior stroke. Mean follow-up was 3.7 years. In multivariable models, female sex, education, diabetes, nonregular alcohol use, prior stroke, Cognitive Abilities Screening Instrument score, depression, mild cognitive impairment, and stroke location were associated with disability. The youngest age quartile had decreased odds of disability over time (odds ratio 0.90 per year, 95% confidence interval 0.85–0.95), whereas the oldest age quartile had increased odds (2.20, 95% confidence interval 1.75–2.75). Americans and Latin Americans had >2-fold greater odds of disability per year compared with Spaniards (p < 0.0001). Conclusions: In lacunar stroke patients, older age was associated with worsening long-term disability, even without recurrence. Worse long-term function was associated with diabetes, cognitive status, and prior stroke, and regional differences may be attributable to variations in health care delivery or scale interpretation.

Objective: To assess the effect of downstream migration of clot fragments on clinical outcome in patients treated with endovascular clot extraction. Background: FDA approval of clot extraction devices is based on technical effectiveness for opening target arteries. Recent randomized trials, however, have failed to demonstrate clinical effectiveness. The role of intraoperative downstream migration of clot fragments has received little attention. Methods: With IRB approval, we reviewed charts, procedure reports, and images of all patients with M1 occlusions treated with endovascular clot extraction within the past 5 years to compare outcomes in patients with "open" arteries (OP) versus "open with fragments" (OF). Results: Thirty four patients were treated under general anesthesia (21 Penumbra, 7 Merci retriever, 6 Solitaire). Numbers of patients in each category of final patency were: OP=15, OF=19. No significant intergroup differences were found (means) for age (60), gender (male 55%), symptom onset to treatment (4.71 hours), admission BP (141/82), duration of anesthesia (2.1 hrs), mean BP during anesthesia (132/70), admission NIHSS (13.8), IV-rtPA (70%) pretreatment. OP patients were more likely to have had an atheroembolic than cardiac source (p<0.03), as well as treatment with Solitaire stent (all 6 Solitaire patients were OP). OF were more likely to have had treatment with IV-rtPA (p<0.15), Penumbra (p<0.03), and adjunctive IA-rtPA and abciximab for the target clot (p<0.09). OP had lower discharge NIHSS (6.79 v 13.22; p<.03); greater NIHSS change (-6.21 v -1.89; p<0.03); discharge mRS=0-2 (47% v 21%; p<0.15); discharge mRS=0-3 (53% v 79%; p<0.005); discharged home (33% v 11%; p<0.2). There was one death in each group (NS); one sICH in OF; length of stay was 8 days in both. Conclusion: Our results strongly suggest an adverse effect of downstream clot fragments. Awareness of this should become part of the approval and post-marketing evaluation of devices.

Background and Purpose: FDA approval of endovascular clot extraction devices that are used in stroke is based on efficacy for opening target arteries safely. Favorable clinical outcomes using devices currently available, however, is limited. Time to treat and stroke severity are obvious contributors, but a factor that receives little attention is intraoperative downstream migration of clot fragments. We assessed the effect of migrated clot fragments on clinical outcome in patients treated at our institution. Methods: With IRB approval, we retrospectively reviewed charts, procedure reports, and images of all patients with M1 occlusions treated with endovascular clot extraction within the past 5 years to compare relevant variables and discharge outcomes in patients whose arteries were ultimately “open” (OP) versus “open with fragments” (OF). Results: Thirty four patients were treated (21 Penumbra, 7 Merci retriever, 6 Solitaire), all under general anesthesia. Numbers of patients in each category of final vessel patency were: OP=15, OF=19. No significant intergroup differences were found (means) for age (60), gender (male 55%), time from onset to treatment (4.71 hours), admission BP (141/82), duration of anesthesia (2.1 hrs), mean blood pressure during anesthesia (132/70), admission NIHSS (13.8), pretreatment with IV-rtPA (70%). OP patients were more likely to have had an atheroembolic than cardiac source of stroke (p<0.03), as well as treatment with Solitaire stent (all 6 Solitaire patients were OP). OF were more likely to have had IV-rtPA (p<0.15), treatment with Penumbra (p<0.03), and adjunctive use of IA-rtPA and abciximab for target clot (p<0.09). OP had lower discharge NIHSS (6.79 v 13.22; p<.03); greater change in NIHSS (-6.21 v -1.89; p<0.03); discharge mRS=0-2 (47% v 21%; p<0.15); discharge mRS=0-3 (53% v 79%; p<0.005); discharged home (33% v 11%; p<0.2). There was one death in each group (NS), one sICH in OF, and length of stay was 8 days in both. Conclusion: Although our numbers are small, they strongly suggest an adverse effect of downstream clot fragments on outcomes. Awareness of this phenomenon should be useful in the approval process for future devices, as well as in the evaluation of post-marketing device use.

OBJECTIVE: To evaluate the utility of basic head CT (CTH) in intravenous rt-PA (IV-rtPA) treatment of stroke with unknown time of onset (UTO).

OBJECTIVE: To validate the observation that emergency department (ED) evaluation of patients presenting with chest pain (CP) and hemisensory stroke symptoms (SS) is predictably negative.

Background: Many patients with stroke-mimicking conditions receive treatment with intravenous fibrinolysis (IVF), a treatment associated with potentially serious complications. We sought to determine if any clinical or radiographic characteristics can help predict stroke mimics among IVF candidates. Methods: This retrospective study was carried out at a single institution. Patients treated with intravenous recombinant tissue plasminogen activator (rt-PA; n = 193) were divided into 3 categories: acute ischemic stroke (n 5 142), aborted stroke (n 5 21), and stroke mimics (n = 30). Analysis of variance and the chi-square test were used to assess differences, while logistic regression models were computed to predict groups. Results: Mimics treated with rt-PA did not experience complications (intracranial bleeding, systemic hemorrhage, or angioedema), and had better neurologic and functional outcomes than stroke patients (P < .05). Several variables helped differentiate strokes from mimics, including atherosclerosis on computed tomographic angiography (odds ratio [OR] 23.6; 95% confidence interval [CI] 8.4-66.2), atrial fibrillation (OR 11.4; 95% CI 1.5-86.3), age >50 years (OR 7.2; 95% CI 2.8-18.5), and focal weakness (OR 4.15; 95% CI 1.75-9.8). Other variables decreased chances of stroke: migraine history (OR 0.05; 95% CI 0.01-0.4), epilepsy (OR 0.13; 95% CI 0.02-0.8), paresthesia (OR 0.1; 95% CI 0.04-0.3), and precordialgia (OR 0.045; 95% CI 0.002-0.9). A regression model using focal weakness, computed tomographic angiography findings, and precordialgia had a 90.2% predictive accuracy. Conclusions: IVF has low complication rates in stroke mimics. Certain clinical characteristics appear predictive of stroke mimics, particularly normal computed tomographic angiography. If confirmed, this may help prevent giving IVF to patients without stroke.

ABSTRACTBACKGROUND AND PURPOSEAlthough transesophageal echocardiography (TEE) is the gold standard for right to left shunt detection, we observed that transcranial Doppler (TCD) was more sensitive and sought an explanation.METHODSWe retrospectively evaluated results of TCD and TEE in 118 patients with cryptogenic stroke and transient ischemic attacks. TCDs were done as per modification of a published performance protocol and interpreted by a neurologist and radiologist. TEEs were performed and interpreted by five cardiologists without standardized protocol. Statistical methodology included χ2 tests, Fisher exact tests, and ANOVA.RESULTSOverall agreement between TCD and TEE was found for 76 of 118 patients. Sensitivities of TCD and TEE were 93.8% and 53.1%. Sensitivities for TCD interpreters were 61.1% and 64.1%. Sensitivities for TEE operators varied from 46.7% to 75.7%. We were unable to find a performance protocol for TEE microbubble studies in either published literature or certification organizations.CONCLUSIONSTEEs and TCDs are operator dependent and thus subject to false negatives. The lower yield and interoperator variability in TEE results appear to reflect the lack of performance protocols and engender concern about false negatives in community use. Consensus performance protocols and certification criteria for both modalities should have an impact on accuracy of shunt detection.

Background and Purpose— Efforts to increase the availability and shorten the time delivery of intravenous thrombolysis in patients with acute ischemic stroke carry the potential for tissue plasminogen activator administration in patients with diseases other than stroke, that is, stroke mimics (SMs). We aimed to determine safety and to describe outcomes of intravenous thrombolysis in SM. Methods— We retrospectively analyzed stroke registry data of consecutive acute ischemic stroke admissions treated with intravenous thrombolysis over a 6-year-period. The admission National Institutes of Health Stroke Scale score, vascular risk factors, ischemic lesions on brain MRI (routinely performed as part of diagnostic work-up), and discharge modified Rankin Scale scores were documented. Initial stroke diagnosis in the emergency department was compared with final discharge diagnosis. SM diagnosis was based on the absence of ischemic lesions on diffusion-weighted imaging sequences in addition to an alternate discharge diagnosis. Symptomatic intracranial hemorrhage was defined as brain imaging evidence of intracranial hemorrhage with clinical worsening by National Institutes of Health Stroke Scale score increase of ≥4 points. Results— Intravenous thrombolysis was administered in 539 patients with acute ischemic stroke (55% men; mean age, 66±15 years). Misdiagnosis of acute ischemic stroke was documented in 56 cases (10.4%; 95% CI, 7.9% to 13.3%). Conversion disorder (26.8%), complicated migraine (19.6%), and seizures (19.6%) were the 3 most common final diagnoses in SM. SMs were younger (mean age, 56±13 years) and had milder baseline stroke severity (median National Institutes of Health Stroke Scale, 6; interquartile range, 4) compared with patients with confirmed acute ischemic stroke (mean age, 67±14 years; median National Institutes of Health Stroke Scale, 8; interquartile range, 10; P <0.001). There was no case of symptomatic intracranial hemorrhage in SMs (0%; 95% CI, 0% to 5.5%); 96% of SMs were functionally independent at hospital discharge (modified Rankin Scale, 0 to 1). Conclusions— Our single-center data indicate favorable safety and outcomes of intravenous thrombolysis administered to SM.

BACKGROUND AND PURPOSE:Efforts to increase the availability and shorten the time delivery of intravenous thrombolysis in patients with acute ischemic stroke carry the potential for tissue plasminogen activator administration in patients with diseases other than stroke, that is, stroke mimics (SMs). We aimed to determine safety and to describe outcomes of intravenous thrombolysis in SM.METHODS:We retrospectively analyzed stroke registry data of consecutive acute ischemic stroke admissions treated with intravenous thrombolysis over a 6-year-period. The admission National Institutes of Health Stroke Scale score, vascular risk factors, ischemic lesions on brain MRI (routinely performed as part of diagnostic work-up), and discharge modified Rankin Scale scores were documented. Initial stroke diagnosis in the emergency department was compared with final discharge diagnosis. SM diagnosis was based on the absence of ischemic lesions on diffusion-weighted imaging sequences in addition to an alternate discharge diagnosis. Symptomatic intracranial hemorrhage was defined as brain imaging evidence of intracranial hemorrhage with clinical worsening by National Institutes of Health Stroke Scale score increase of ≥4 points.RESULTS:Intravenous thrombolysis was administered in 539 patients with acute ischemic stroke (55% men; mean age, 66 ± 15 years). Misdiagnosis of acute ischemic stroke was documented in 56 cases (10.4%; 95% CI, 7.9% to 13.3%). Conversion disorder (26.8%), complicated migraine (19.6%), and seizures (19.6%) were the 3 most common final diagnoses in SM. SMs were younger (mean age, 56 ± 13 years) and had milder baseline stroke severity (median National Institutes of Health Stroke Scale, 6; interquartile range, 4) compared with patients with confirmed acute ischemic stroke (mean age, 67 ± 14 years; median National Institutes of Health Stroke Scale, 8; interquartile range, 10; P<0.001). There was no case of symptomatic intracranial hemorrhage in SMs (0%; 95% CI, 0% to 5.5%); 96% of SMs were functionally independent at hospital discharge (modified Rankin Scale, 0 to 1).CONCLUSIONS:Our single-center data indicate favorable safety and outcomes of intravenous thrombolysis administered to SM.

HomeStrokeVol. 41, No. 4Response to Letter by Tsivgoulis et al Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBResponse to Letter by Tsivgoulis et al Jose Rafael Romero, MD Lee H. Schwamm, MD, FAHA James L. Frey, MD Bart M. Demaerschalk, MD Hari P. Chaliki, MD Gunjan Parikh, MD Viken Babikian, MD Jose Rafael RomeroJose Rafael Romero Department of Neurology, Boston University Medical Center, Boston University School of Medicine, Boston, Mass, Framingham Heart Study, Framingham, Mass Lee H. SchwammLee H. Schwamm Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass James L. FreyJames L. Frey Division of Neurology, Barrow Neurological Institute, Phoenix, Ariz Bart M. DemaerschalkBart M. Demaerschalk Department of Neurology, Mayo Clinic Hospital, Phoenix, Ariz Hari P. ChalikiHari P. Chaliki Department of Neurology, Mayo Clinic Hospital, Phoenix, Ariz Gunjan ParikhGunjan Parikh Division of Neurology, Barrow Neurological Institute, Phoenix, Ariz Viken BabikianViken Babikian Department of Neurology, Boston University Medical Center, Boston University School of Medicine, Boston, Mass Originally published11 Feb 2010https://doi.org/10.1161/STROKEAHA.109.563668Stroke. 2010;41:e196Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: February 11, 2010: Previous Version 1 Response:We are thankful to Dr Tsivgoulis and his coauthors for their interest in our article. With regard to their first comment, although we cannot entirely exclude the possibility that an alternative, coincidental source of embolism was present, we consider its likelihood to be minuscule. The patient was monitored with telemetry during her entire hospitalization and at no time had a dysrhythmia, nor did she have a history of dysrhythmic symptoms before or after the index stroke. The writers also suggest that she may not have even had a right to left shunt because her transthoracic echocardiography failed to show one. This is similarly difficult to accept because it is widely acknowledged that transthoracic echocardiography is the least sensitive of all available modalities for detecting a shunt, and the transcranial Doppler (TCD) study findings strongly suggested one. Our statement that "TTE (transthoracic echocardiography) was negative for embolic source and was considered insufficient evidence of PFO (patent foramen ovale)" was intended to mean that a negative TTE was insufficient to rule out a PFO.Tsivgoulis et al also state, "The authors do not report the results of the TCD study that may assist in elucidating the underlying mechanism of IS (ischemic stroke) in this patient." The TCD study detected high-intensity transient signals strongly suggestive of a right-to-left shunt, but it was nonrevealing otherwise. In the Table, we described the finding as "possible PFO" because a positive TCD bubble study cannot identify the precise anatomy and location of the shunt.Tsivgoulis et al imply that a TCD bubble study protocol described in a consensus article is in fact an accepted standard and that the use of the protocol protects against paradoxical air embolism. Although we acknowledge that variations in the technique to perform a bubble study exist between different centers, our experience raises concern about risk. We see no reason why paradoxical air embolism would be less likely to occur during TCD than TTE or transesophageal echocardiography, nor is there published "evidence" that this is the case. The absence of reported cerebral ischemic events does not mean that none are occurring, as we discussed in the article; it is the novel use of the listserve that surfaced these reports because it aggregates rare events.The purpose of our article is to alert readers about the transient ischemic attack and stroke risk associated with echocardiography and TCD bubble studies. The 5 patients presented in the article exemplify this complication. We wish to emphasize that such a risk can only be properly assessed when these procedures are performed in accordance with a standardized protocol and data are gathered prospectively in the context of a structured study.DisclosuresJ.L.F. is on the speakers bureaus for Bristol Myers Squibb, EKT Pharma, Genentech, and Sanofi-Aventis. B.M.D. is the ESCAPE trial site principal investigator sponsored by St Jude Medical and the RESPECT trial site principal investigator sponsored by AGA. V.L.B. is a consultant for Boston Scientific and is on the speakers bureau for Boehringer Ingelheim. The remaining authors have no conflicts of interest to report. Previous Back to top Next FiguresReferencesRelatedDetails April 2010Vol 41, Issue 4 Advertisement Article InformationMetrics https://doi.org/10.1161/STROKEAHA.109.563668 Originally publishedFebruary 11, 2010 PDF download Advertisement