Background: Stroke is a leading cause of hospital admissions among the elderly, and reducing readmission rates has become a primary goal of healthcare reform. Hospitals are now being held financially responsible for 30 day readmission rates exceeding their expected rate [1]. Our aim was to determine if patients seen in the comprehensive stroke discharge clinic had reduced 30 day readmissions compared to standard hospital follow up after ischemic stroke. Methods: Patients with a discharge diagnosis of ischemic stroke receive a phone call from the neurology office staff within 3 business days of hospital discharge to schedule an appointment with a mid-level provider in the comprehensive stroke discharge clinic within 1-3 weeks. Eligibility for the clinic includes patients ≥ 18 years of age that are either discharged to home directly or discharged to home from inpatient rehabilitation. We performed a retrospective stroke database search of patients meeting this criteria from May 2015 to June 2016. Patients were excluded from the search if they had an inpatient stroke event. Results: Of the 526 patients reviewed, 116 patients (22.1%) were seen in the comprehensive stroke discharge clinic. The average age of patients seen in clinic was 67 years and the average age of patients in the non-clinic group was 69 years. Approximately 12% of patients in each group received acute reperfusion therapy. There was only one 30 day related readmission in the clinic group, and fourteen 30 day related readmissions in the non-clinic group (0.86% versus 3.41%; 95% CI 0.12-4.99%). There were eight 30 day all cause readmissions in the clinic group, and forty-two 30 day all cause readmissions in the non-clinic group (6.90% versus 10.24%; 95% CI -2.12-8.81%). Conclusion: The comprehensive stroke clinic model may reduce 30 day related readmissions for patients discharged to home. However, there were limitations to this study. The percentage of patients seen in the comprehensive stroke clinic was low. The goal is to improve the clinic follow up rate over the course of the next year. In addition, patients were excluded from the clinic if they were discharged to a skilled nursing facility, which is often associated with a higher readmission rate.

Background: Rapid assessment of patients that present to the emergency center with acute stroke symptoms is crucial to the timely administration of intravenous thrombolysis. The “golden hour” is recognized by the American Heart Association as the standard of care for treatment of acute ischemic stroke [1]. Door to treatment in ≤ 60 minutes can be difficult to achieve, and in 2010 < 30% of hospitals participating in GWTG attained this goal [2]. One step that can be particularly challenging during the expedited stroke assessment is door to head CT interpretation time in ≤ 45 minutes. We sought to determine factors that delay head CT turnaround times > 45 minutes. Methods: A retrospective stroke database review was completed on 165 patients presenting to the emergency center with acute stroke symptoms in the 0-4.5 hour time window from January 2014 to May 2015. Inclusion criteria was age 18-95 years with an initial NIHSS of 1-42, and a head CT completed at our hospital. Inpatients that developed acute stroke symptoms were excluded from the study. Patients were further stratified by NIHSS and age. Results: The mean age was 75 years and 50% were female. The average head CT turnaround time was 38.1 minutes and the average NIHSS was 8.11. Fifty three patients (32.1%) received acute reperfusion therapy. The average head CT turnaround time for a NIHSS of 1-3 was 47.4 minutes; NIHSS of 4-9 was 38.4 minutes; NIHSS of 10-24 was 25.2 minutes; NIHSS ≥ 25 was 34.5 minutes. There was no significant difference in the head CT turnaround time based on age. Conclusion: Patients presenting to the emergency center with a NIHSS of 1-3 had delayed head CT turnaround times compared to patients presenting with more severe stroke symptoms, and furthermore, did not meet the goal head CT interpretation time of ≤ 45 minutes. One possible reason for this finding is that patients with minor stroke symptoms are less likely to receive intravenous thrombolysis. However, expanding literature suggests that nearly 30% of patients with lower NIHSS scores at discharge have significant disability at 90 days [3]. Multiple educational interventions will be implemented in the emergency center to improve head CT turnaround times in patients with low NIHSS scores on presentation.

Stroke is a global health problem. However, very little is known about stroke care in low-to middle-income countries. Obtaining country-specific information could enable us to develop targeted programs to improve stroke care. We surveyed neurologists from 12 countries (Chile, Georgia, Nigeria, Qatar, India, Lithuania, Kazakhstan, Indonesia, Denmark, Brazil, Belgium, and Bangladesh) using a web-based survey tool. Data were analyzed both for individual countries and by income classification (low income, lower middle income, upper middle income, and high income). Six percent (n = 200) of 3123 targeted physicians completed the survey. There was a significant correlation between income classification and access and affordability of head computed tomography scan (rho = .215, P = .002), transthoracic echocardiogram (rho = .181, P = .012), extracranial carotid Doppler ultrasound (rho = .312, P <= .000), cardiac telemetry (rho = .353, P < .000), and stroke treatments such as intravenous thrombolysis (rho = .276, P <= .001), and carotid endarterectomy (rho = .214, P <= .004); stroke quality measures suchas venous thromboembolismprophylaxis duringhospital stay (rho = .163, P <= .022), discharge from hospital on antithrombotic therapy (rho = .266, P <= .000), consideration for acute thrombolytic therapy (rho = .358, P <= .000), and antithrombotic therapy prescribed by end of hospital day 2 (rho = .334, P <= .000). However, there was no significant correlation between income classification and the access and affordability of antiplatelet agents, vitamin K antagonists and statins, anticoagulation for atrial fibrillation/flutter, statin medication, stroke education, and assessment for rehabilitation. Our study shows that it is possible to get an overview of stroke treatment measures in different countries by conducting an internet-based survey. The generalizability of the findings may be limited by the low survey response rate. (C) 2015 by National Stroke Association

Background: Telestroke is an increasingly used mode of assessment of acute stroke patients when vascular neurologists are not available onsite. We provided onsite stroke hospitalist services at a local community hospital via onsite, bedside assessment for 18 months. Coverage was then transitioned to telestroke only assessment, at the same hospital with the same vascular neurologists. We sought to determine if IV r-tPA rates changed. Methods: Onsite coverage was from April 2011 through September 2012 (Group 1). Telestroke only coverage was from October 2012 through July 2013 (Group 2). We reviewed all acute stroke codes and determined which patients were treated with IV r-tPA. We also collected door to needle (DTN) times. Fisher’s exact and independent t-tests were used where appropriate. Results: In Group 1 there were 578 acute stroke codes. 52 of these patients (8.9%) received IV r-tPA. Group 2 had 356 acute stroke codes, 29 of which received IV r-tPA (8.1%). This difference was not statistically significant (p=0.7201). Mean number of patients treated with IV r-tPA per month was 2.8 for Group 1 and 2.9 for Group 2. Mean DTN time was 76.73 min for Group 1 and 90.63 min for Group 2. This shows a trend toward shorter DTN times with bedside assessment but this difference is not statistically significant (p=0.0798). Conclusion: IV r-tPA administration rates do not fall when a telestroke only coverage model replaces an onsite model. This suggests that telestroke coverage is sufficient to maintain IV r-tPA treatment rates, even when vascular neurologists are not available at the bedside.

Warfarin, a vitamin K epoxide reductase inhibitor, is the oral anticoagulant most commonly used to reduce the risk of stroke in patients with atrial fibrillation (AF). Warfarin has proved to be efficacious for this purpose in multiple clinical trials. However, warfarin use is laborious and associated with an increased risk of intracranial hemorrhage (ICH). Various factors increase the risk of warfarin-related ICH, including older age, intensity of anticoagulation, hypertension, and history of cerebrovascular disease. The emergence of newer classes of oral anticoagulants will offer therapeutic alternatives to reduce the risk of stroke in patients with AF. Recently, the United States Food and Drug Administration approved 3 new agents--dabigatran etexilate, a direct thrombin inhibitor, and rivaroxaban and apixaban, factor Xa inhibitors-to reduce the risk of stroke and systemic embolism in patients with nonvalvular AF. We discuss the incidence, mortality, and risk factors predisposing to oral anticoagulant-associated ICH in patients with AF.

OBJECTIVE: To validate GRASPS score in an independent cohort. BACKGROUND: The recently developed GRASPS score predicts risk for symptomatic intracerebral hemorrhage (sICH) within 36 hours post intravenous tissue plasminogen activator (iv-tPA) infusion. In the original study, sICH adjudication was based on documentation but neuroimaging was not centrally available. DESIGN/METHODS: Consecutive acute ischemic stroke (AIS) patients admitted to our institutions between January 2011 and July 2012, and treated with iv-tPA were identified. Age, race/ethnicity, sex, NIHSS, blood pressure, and glycemia at presentation were obtained, and GRASPS scores calculated. Charts were reviewed looking for neurological deterioration and sICH at 36h post iv-tPA infusion. Neuroimaging was used to confirm the diagnosis of sICH. Scores were analyzed for sensitivity and specificity and the C-statistic calculated based on the receiver operating characteristic (ROC) curve. RESULTS: A total of 41 cases treated with iv-tPA within 3 hours of symptom onset were identified and analyzed. Our study population was predominantly white (73.2%), male (54%), with a median age of 79±13 years, and median NIHSS of 14±8 at baseline. Symptomatic ICH occurred in 6 cases. GRASPS scores ranged between 49 and 87, and the ROC area under the curve was 0.73 (95% CI = 0.48-0.98). A score of ≥86 had a positive likelihood ratio of 8.8 and correctly classified 87.8% of the population. Using this cut-off, the specificity was 94.3% and the sensitivity was 50.0%. CONCLUSIONS: The GRASPS score may be a useful prediction tool for the risk of sICH in AIS patients receiving iv-tPA within 3 hours of symptom onset. A higher GRASPS score, specifically 86 and higher, predicts the occurrence of sICH; however, the score had a low sensitivity. Our findings underscore the need for prospective validation of the GRASPS score in different clinical settings with diverse study population. Disclosure: Dr. Ong has nothing to disclose. Dr. Nouh has nothing to disclose. Dr. Pandey has nothing to disclose. Dr. Grysiewicz has nothing to disclose. Dr. Khaja has nothing to disclose. Dr. Shafi has nothing to disclose. Dr. Ruland has received personal compensation for activities with AstraZeneca Pharmaceuticals and Boehringer Ingelheim Pharmaceuticals, Inc. Dr. Hillmann has nothing to disclose. Dr. Hoelzel has nothing to disclose. Dr. Castillo has nothing to disclose. Dr. Testai has nothing to disclose.

Background: It is estimated that only 1-3% of ischemic stroke patients receive IV r-tPA. There are multiple reported barriers that impede the administration of IV-tPA in ischemic stroke patients. However, one specific barrier continually cited by emergency room physicians is a lack of neurological support. In addition, many general neurologists do not regularly treat stroke patients, and therefore do not feel comfortable administering IV r-tPA. We sought to determine if 24/7 availability of vascular neurologists either at the bedside or via telemedicine would increased the frequency IV r-tPA administration in a local community hospital compared to general neurologists via phone consultation. Methods: We reviewed the stroke database and determined how many patients presenting with an acute ischemic stroke received IV r-tPA within 4.5 hours during the 14 months before and the 14 months after the implementation of 24/7 vascular neurology availability. We also collected patient age, time of onset, time of arrival, and NIH stroke scale. The student’s t-test or Fisher’s exact test was used to calculate p values for significance when appropriate. Results: Between January 1, 2010 and March 22, 2011, 408 stroke emergencies were activated and 7 patients received IV r-tPA under the consultation of general neurologists. Between March 23, 2011 and May 27, 2012, 291 stroke emergencies were activated and 39 patients received IV r-tPA under the consultation of vascular neurologists (1.7% vs. 13.4%, p<0.0001). The mean NIHSS for patients that received IV r-tPA before the 24/7 vascular neurology availability was 11.80, and the mean NIHSS for patients that received IV r-tPA after the 24/7 vascular neurology availability was 13.86 (p=0.61). In 2012, a change in the time window criteria of when to activate an acute stroke emergency decreased the number of stroke emergencies recorded in the second half of the database. Conclusion: The 24/7 availability of vascular neurologists increased the IV r-tPA administration rate by more than 5 fold. Access to stroke expertise significantly improves the number of ischemic stroke patients that receive IV r-tPA within 4.5 hours.

OBJECTIVE: We sought to investigate the risk of intracerebral hemorrhage and safety of IV r-tPA in nonagenarians.

Background: Telestroke is a promising avenue for treatment of acute stroke patients when a vascular neurologist is not available for bedside assessment. We provide stroke hospitalist services at a local community hospital Monday-Friday, supplemented by telestroke coverage by the same vascular neurologists on night and weekends. We compared door-to-needle (DTN) times via telestroke vs. at the bedside. Methods: We reviewed cases of acute ischemic stroke patients who received IV r-tPA treatment and determined whether they were assessed at the bedside vs. telestroke. We collected age, risk factors, symptom onset time, admission NIH stroke scale, DTN time, and discharge disposition. A favorable discharge disposition was considered home or acute rehab. Mann-Whitney U and Fisher’s Exact tests were used when appropriate. Results: Between April 2011 and May 2012, 39 patients were treated with IV r-tPA, 49% (19/39) at the bedside, and the remainder (20/39, 51%) via telestroke. Table 1 is a comparison of the baseline characteristics. The bedside group was slightly older with a higher incidence of atrial fibrillation, but this difference was not significant. Mean DTN times were not significantly different in the bedside group (mean 76.1±34.9 min) compared with the telestroke group (83.5±29.5 min) (p=0.15). Goal DTN times of <60min were met in 9 (47%) of the bedside group versus 4 (20%) in the telestroke group (p=0.06) Mean symptom onset to treatment time was 150.6±61.2 min in the bedside group, versus 145.9±41.0 min in the telestroke group (p=0.46). 9 patients (47%) in the bedside group had a favorable discharge, compared with 15 (75%) in the telestroke group (p=0.21). Conclusion: In a community hospital, there was no significant difference between door-to-needle times in patients treated with IV r-tPA at the bedside versus via telestroke. This supports the use of telestroke to provide extended coverage to hospitals.

Cerebral congophilic or amyloid angiopathy (CAA) is a clinicopathological entity that is considered a common cause of primary non-traumatic brain haemorrhage in the elderly. CAA is frequently associated with Alzheimer’s disease (AD) and has become a primary focus of scientific inquiry. The spectrum of intracerebral haemorrhage (ICH) that may occur in CAA includes: cerebral lobar haemorrhages, deep haemorrhages, purely subarachnoid and subdural haemorrhages and cerebral microbleeds. CAA is also associated with microinfarcts, leukoencephalopathy and superficial siderosis. This brief article will provide an update on the advances in our understanding of CAA-associated ICH with a focus on the following topics: neuropathology and mechanism of CAA-related haemorrhage; epidemiology, including genetic and other possible risk factors; clinical presentation; diagnosis, including newer imaging modalities; and prospects for prevention and treatment.

In the USA, hypertension affects approximately 76% of men and 64% of women by 75 years of age. Among the 73 million individuals in the USA with hypertension, almost 80% are aware of their high blood pressure and 69 % receive antihypertensive treatment. However, less than 50% have controlled blood pressure, placing these individuals at risk for developing neurological emergencies such as hypertensive crisis and intracerebral hemorrhage (1).

The epidemiology of ischemic and hemorrhagic stroke is an ongoing exploration to identify risk factors that continue to expand with the advent of technological advancements and preventative medical practices. Identification of risk factors that can or cannot be modified is a crucial step in determining stroke risk. Many of the modifiable risk factors are well established, and specific interventions to reduce stroke risk have been established. Some risk factors are less established, and intervention to reduce risk is yet to be determined by evidence-based medicine. Data from ongoing randomized clinical trials continue to enhance our ability to prevent a first stroke.