BACKGROUND:Many patients with acute ischaemic stroke require interhospital transfer for endovascular therapy. We sought to determine whether door-in-door-out (DIDO) time is associated with functional outcomes. METHODS:We conducted a retrospective cohort study of patients with acute ischaemic stroke and a visualised target occlusion on cerebrovascular imaging who were transferred from acute care hospitals to hospitals participating in the US nationwide Get With The Guidelines-Stroke registry for endovascular therapy evaluation between Jan 1, 2019, and Dec 31, 2023. The primary exposure was DIDO time (time from arrival to discharge from the presenting emergency department). Patients were followed up until hospital discharge. The primary outcome was ordinal modified Rankin Scale (mRS) score at hospital discharge, from which we calculated the odds of a 1-point increase (ordinal shift) in the mRS score at discharge. Secondary outcomes were mRS dichotomies (mRS score 3-6 vs 0-2 and mRS score 4-6 vs 0-3), receipt of endovascular therapy, discharge ambulatory status, and complications after reperfusion therapy. We used generalised linear mixed models with sequential adjustment for demographics, risk factors, receiving hospital, and clinical characteristics. FINDINGS:Among 22 410 patients with acute ischaemic stroke (median age 70 years [IQR 60-80]; 11 236 [50·1%] female; 16 558 [73·9%] White, 3146 [14·0%] Black or African American, 1338 [6·0%] Hispanic) transferred for endovascular therapy evaluation, median DIDO time was 121 min (IQR 89-175). Endovascular therapy was performed in 16 976 (75·8%) patients at the receiving hospital. Compared with 90 min or less, longer DIDO times were associated with higher odds of a 1-point increase in mRS score at discharge (91-180 min: adjusted odds ratio [aOR] 1·29, 95% CI 1·20-1·37; 181-270 min: 1·49, 1·36-1·64; >270 min: 1·70, 1·53-1·89) and lower odds of endovascular therapy receipt (91-180 min: 0·71, 0·65-0·79; 181-270 min: 0·50, 0·44-0·57; >270 min: 0·35, 0·30-0·40). Results were similar for mRS dichotomies. Longer DIDO time was also associated with reduced independent ambulation and increased complications after reperfusion therapy. INTERPRETATION:Longer DIDO times were strongly associated with lower rates of endovascular therapy, higher rates of complications, and worse functional outcomes. System-level strategies to minimise DIDO time are essential to optimise acute ischaemic stroke care and improve outcomes. FUNDING:None.

Abstract Background and aims Telestroke aims to provide rapid expert evaluation and evidence-based treatment to patients with acute ischemic stroke (AIS) in hospitals without on-site stroke specialists. However, intravenous (IV) thrombolysis and interhospital transfers are often delayed in telestroke-managed patients. We evaluated perceived drivers of these delays by surveying hospitals from a statewide acute stroke registry. Methods The Paul Coverdell Michigan Acute Stroke Registry (MASR) has collected stroke data since 2003 to measure and improve care. Currently MASR includes over 50 hospitals, representing 64% of the state’s stroke cases. Our team developed telestroke-specific questions for the 2025 MASR Hospital Inventory Survey, administered annually to hospital stroke program coordinators. We asked spoke sites (where telestroke call is initiated from) to identify the main causes of delay in 1) IV thrombolytic therapy delivery and 2) interhospital transfer when using telestroke. Results Of 53 MASR hospitals, 46 (87%) participated in the Inventory Survey. Of these, 18 were telestroke spoke sites. The top 3 identified sources of delay in thrombolytic therapy at the spoke sites were: determining patient eligibility (50%), obtaining consent (38.9%), and diagnosing stroke (22.2%). The top three sources of delay in interhospital transfer were: securing interhospital transport (44.4%), determining patient eligibility for transfer (27.8%), and identifying an accepting facility (22.2%). Conclusions A state-level stroke registry survey identified key perceived drivers of thrombolytic and transfer delays within telestroke systems. These results highlight modifiable targets to improve telestroke care and support future work incorporating diverse telestroke provider perspectives. Conflict of interest Brian Stamm: nothing to disclose. Ghada Ibrahim: nothing to disclose. Adrienne Nickles: nothing to disclose. Regina Royan: reported receiving a grant from the National Institute of Neurological Disorders and Stroke (K12NS137516) during the conduct of the study. Rodney Hayward: nothing to disclose. Mollie McDermott: nothing to disclose. Phillip Scott: reported receiving grants from NIH during the conduct of the study. Kevin Sheth: reported receiving grants from NIH during the conduct of the study; grants from Hyperfine, Genentech, and the American Heart Association; and personal fees from Astrocyte, Bexorg, and BrainQ outside the submitted work; and an issued patent for Alva. Mathew Reeves: nothing to disclose. Deborah Levine: reported receiving grants from NIH and consulting fees on NIH grants from Tufts University and Northwestern University outside the submitted work. Figure 1 - belongs to Conclusions

Background: Timely prehospital care is the first link in the stroke chain of survival, yet large-scale data on how specific EMS intervals affect acute stroke treatment are limited. We evaluated the association between delays in prehospital care and receipt of IV thrombolysis, endovascular therapy (EVT), and anticoagulation (AC) reversal in a national stroke registry. Methods: This was a retrospective cohort analysis of EMS-transported stroke cases from the American Heart Association Get With The Guidelines-Stroke National Registry (January 1, 2018 to August 31, 2023). Delays in EMS care were defined per guidelines or median values: dispatch to scene arrival (>8 min); scene time (>15 min); scene departure to ED arrival (>15 min); and total prehospital interval (> 40 min). Outcomes included receipt of IV thrombolysis and EVT for patients with acute ischemic stroke (AIS), and AC reversal for patients with hemorrhagic stroke. Logistic regression models with generalized estimating equations (GEE) for intervention-eligible patients controlled for patient demographics, insurance status, past medical history, and hospital characteristics. Race-based interaction terms were tested for effect modification. Results: There were 261,689 AIS patients with last known well ≤4 hours (IV thrombolysis-eligible), 333,527 patients with LKW time ≤24 hours (EVT-eligible), and 13,306 patients with hemorrhagic stroke. Delays in all prehospital intervals significantly reduced the odds of receiving thrombolysis, while delays in scene time, scene departure to ED arrival, and total prehospital interval significantly reduced the odds of EVT; delays were not associated with AC reversal (Figure 1). Longer scene time was associated with longer door-to-needle and door-to-groin times (Figure 2a-b). There was a significant interaction effect by race on the association between prehospital scene time delays and receipt of thrombolysis (p<.001) and EVT (p=.004), with effect sizes varying across racial subgroups (Figure 3). Discussion: Prehospital delays are strongly associated with reduced odds of receiving proven acute ischemic stroke treatments, including thrombolysis and EVT. Targeted strategies to minimize these delays are critical for optimizing stroke care.

Background Social media has become a central channel for the dissemination of health information, enabling rapid sharing of evidence-based guidance while also facilitating the spread of inaccurate or misleading content. Exposure to such information has been associated with changes in vaccination-related attitudes and decision-making. These effects may not occur uniformly across populations, and there is limited understanding of how health information circulates within Spanish-language social media networks or which communication strategies are most effective in promoting engagement and informed decision-making. This study describes a protocol to evaluate a community-engaged intervention designed to address these gaps. Methods This study will use a non-randomized stepped-wedge design to evaluate the implementation and effectiveness of the Dime La VerDAD intervention across community-based cohorts of promotores de salud in Chicago. Promotores will be grouped into geographically defined clusters and will transition from control to intervention at six-month intervals, such that all clusters receive the intervention by study end. The intervention will consist of a structured, bilingual training program focused on identifying inaccurate health claims, evaluating source credibility, and developing accessible, evidence-based social media content, including narrative-based messaging. Outcomes will be assessed using surveys, focus groups, social media analytics, and publicly available epidemiologic data. Primary and secondary outcomes will include changes in knowledge, communication practices, engagement with social media content, and vaccination-related decision-making. Analyses will use mixed-effects models to evaluate changes over time while accounting for clustering and repeated measures. Discussion This study will generate evidence on how health information is shared and interpreted within Spanish-language social media networks and evaluate whether a structured, community-engaged communication intervention improves the quality and reach of health messaging. Findings will inform the development of scalable, community-based strategies to support dissemination of reliable health information and promote informed decision-making in diverse populations. Trial registration: ClinicalTrials.gov NCT06417762. Recruitment has begun and is ongoing at the time of manuscript submission.

Despite significant progress in hospital quality initiatives and the organization of regional stroke systems of care, a significant gap persists between the number of patients eligible for acute ischemic stroke reperfusion therapies and those who receive them in a timely manner. This gap reflects persistent delays and variability across the prehospital and interhospital phases of care, from prehospital dispatch and field assessment to destination selection and interhospital transfer workflows. This expert narrative review synthesizes current evidence on acute stroke systems of care, with a particular focus on prehospital identification of stroke, destination decision-making for suspected large-vessel occlusion, and interhospital transfer for patients requiring endovascular thrombectomy. Key processes, including prehospital response and scene times, destination decision-making, and door-in-door-out metrics, are examined to illustrate how system-level bottlenecks affect access to and outcomes of reperfusion therapies. Emerging and novel technologies are also described, including mobile stroke units, blood-based biomarkers for prehospital stroke diagnosis, portable neuroimaging modalities, physiological and device-based detection systems, and cross-cutting tools such as telestroke, all aimed at shifting accurate diagnosis and treatment decisions earlier in the stroke care pathway.

Background: Elevated systolic blood pressure (SBP) is common in acute intracerebral hemorrhage (ICH). While early BP lowering is evidence-based and guideline-recommended, the factors associated with higher presenting SBP and the relationship with in-hospital outcomes across the full SBP spectrum remain unclear. Methods: This was a retrospective cohort analysis of the Hemorrhagic Stroke Data Layer of the American Heart Association Get With The Guidelines-Stroke National Registry from Feb 8, 2023 to Jan 1, 2025. Patients with ICH were categorized by presenting SBP: normal (<150 mmHg), elevated (150–219 mmHg), and severely elevated (≥220 mmHg). Presenting SBP was defined as the first recorded measurement prior to or after hospital arrival. Multivariable models identified independent factors associated with elevated or severely elevated presenting SBP. Discharge outcomes for patients (including discharge destination, ability to ambulate, discharge mRS, and in-hospital mortality or discharge to hospice) were modeled as a function of presenting SBP while adjusting for patient demographics, presenting features, and hospital characteristics. Non-linear associations for SBP and age were modeled using smoothing splines. Results: 82,857 patients with ICH were included, with 25,353 (30.6%) having normal presenting SBP, 47,975 (57.9%) with elevated SBP, and 9,529 (11.5%) with severely elevated SBP. Age >45, Black and Asian race (vs White), history of hypertension, renal insufficiency, and increasing stroke severity as measured by NIHSS were associated with higher odds of elevated presenting SBP. History of prior stroke, private transportation method, and use of pre-ICH antithrombotic agents were associated with lower odds of elevated presenting SBP (Figure 1A-B). There were non-linear associations between presenting SBP and odds of ambulation at discharge (reverse U-shape) and discharge to home (reverse J-shape) (Figure 2A-B). There was a U-shaped association between presenting SBP and odds of death or discharge to hospice and discharge mRs of 3-6 (vs 0-2) (Figure 3A-B). Discussion: Presenting SBP in ICH exhibits a U-shaped association with mortality and functional outcomes, with both extremes associated with higher risk. These findings suggest that avoiding both under- and over-treatment may be critical in early ICH care. Prospective studies should evaluate whether there is a time treatment interaction with rapid SBP reduction, especially at the high end of this curve.

BACKGROUND:Timely identification and treatment of acute ischemic stroke (AIS) in the emergency department is imperative. We sought to report the change over time in emergency department-based AIS treatment in a community without an academic medical center through a mixed-methods approach. METHODS:As part of the longitudinal population-based BASIC (Brain Attack Surveillance in Corpus Christi) project, Nueces County residents 45+ years old with AIS treated in an emergency department were identified, excluding patients with in-hospital events. Logistic regression was used to model changes over time from 2012 to 2022, treating time continuously, for the binary outcomes National Institutes of Health Stroke Scale score documentation, transfer to an out-of-area facility, thrombolytic (tPA/TNK [tissue-type plasminogen activator/tenecteplase]) utilization, and arrival method. Trends for neurology consults and telestroke consults were evaluated from 2015 to 2022 based on data availability. Logistic regression models accounted for subject repeated measures and within-hospital clustering. Rapid qualitative analysis procedures were used to analyze semistructured interviews of emergency medicine (EM) physicians. RESULTS:A total of 5388 strokes were included. National Institutes of Health Stroke Scale documentation by provider increased by 12.9% (95% CI, 0.057-0.202). The overall proportion of neurology consultation increased by 26% (95% CI, 0.159-0.360). Among these, the proportion of telestroke consults increased by 34.2% (95% CI, 0.218-0.465). Patient transfer to an out-of-area facility saw a peak around 2020 (3.2%) that declined by 2022 (0.0%). tPA/TNK treatment increased by 5.5%, but was not statistically significant (95% CI, -0.006 to 0.116). Arrival to the emergency department by emergency medical services decreased by 9.4% (95% CI, -0.181 to -0.007). Fifty-two practicing emergency medicine physicians in Nueces County were recruited via email between April and October 2024, yielding 18 interviews. Participants described improved organization of stroke care and confidence in treating AIS. CONCLUSIONS:There have been positive changes in AIS treatment from the emergency medicine perspective, suggesting the success of assertive treatment protocols in this real-world community.

Introduction: There is minimal real-world data on whether stroke process quality metrics differ for intracerebral hemorrhage (ICH) and acute ischemic stroke (AIS) and if they have changed over time. Identifying and addressing these differences may inform targeted quality improvement initiatives to optimize acute stroke outcomes. Methods: AIS and ICH patients admitted to Get With The Guidelines-Stroke participating hospitals from Jan 1, 2015 to June 30, 2024 who arrived by emergency medical services (EMS) were included. Outcomes included prehospital-based process metrics (EMS prenotification, last known well (LKW) and stroke symptom onset to ED arrival time) and ED-based metrics (door to ED physician assessment; door to stroke team activation; door to stroke team arrival; door to first stroke severity score; door to initial brain imaging order; and door to initial brain imaging report). Generalized estimating equations were used in logistic and linear regression models to evaluate the association between stroke type (ICH vs AIS) and outcomes, with sequential adjustment for patient demographics, medical history and presenting factors, and hospital characteristics. Temporal trends of prehospital care metrics were examined. Results: 195,659 patients (N=31,464 with ICH; N=164,195 with AIS) from 195 hospitals were included. The median (IQR) NIHSS was 14 (6-23) for ICH vs 6 (2-13) for AIS (absolute standardized difference 69.4). ICH (vs AIS) was associated with higher odds of door to ED physician assessment ≤10 mins after adjusting for patient demographics (aOR 1.08, 95% CI 1.02, 1.14). This association reversed after adding adjustment for medical history and presenting factors (including NIHSS), and hospital characteristics (aOR 0.94, 95% CI 0.89, 0.99). A similar pattern was observed for door to initial brain imaging order ≤20 mins (demographic-adjusted: aOR 1.09, 95% CI 1.02, 1.16; fully adjusted with medical history and hospital characteristics: aOR 0.91, 95% CI 0.85, 0.97). Median LKW to arrival time increased by 32.5% for AIS (151 to 200 min; p < .0001) and 34.3% (108 min to 145 min; p < .0001) for ICH over the study period. Discussion: From 2015 to 2024, patients with ICH were less likely to achieve timely ED-based process metrics compared to patients with AIS, despite faster presentation to the ED. Future quality improvement initiatives should target these differences to ensure all patients with stroke receive time-sensitive care.

Background Patients with anticoagulation‐associated intracerebral hemorrhage are often transferred from the presenting hospital to one with additional resources. Understanding differences in timeliness and care, including anticoagulant reversal, between transfer and direct admissions may identify quality improvement opportunities. Methods This cross‐sectional study included all hospitals in the American Heart Association GWTG–Stroke (Get With The Guidelines–Stroke) registry where anticoagulant reversal was administered (2015–2021). Patients with anticoagulation‐associated intracerebral hemorrhage presenting within 24 hours of onset and with information on prior AC treatment were included. Outcomes included functional score at discharge, in‐hospital death/discharge to hospice, discharge ambulatory status, discharge destination, and length of stay. Results Of 30 590 patients with AC‐ICH, 14 882 (48.6%) were transfers. Symptom onset to AC reversal was longer for transfer patients who received anticoagulant reversal at the admitting hospital versus direct‐admission patients (512 [interquartile range 328–840] versus 273 [interquartile range, 153–579] minutes; absolute standardized mean difference, 75.9%). Transfer patients had milder stroke severity on admission versus direct‐admission patients on the basis of National Institute of Health Stroke Scale (7 [interquartile range, 2–19] versus 11 [interquartile range, 3–22]; absolute standardized mean difference, 21.2%) and intracerebral hemorrhage scores (1.81±1.36 versus 2.02±1.47; absolute standardized mean difference, 13.7%). In an adjusted logistic regression model, transfer patients had lower odds of in‐hospital death/discharge to hospice (adjusted odds ratio, 0.78 [95% CI, 0.72–0.85]), but no difference in discharge functional score, ambulatory status, or discharge home versus direct‐admission patients. Conclusions Transfer patients with anticoagulation‐associated intracerebral hemorrhage had longer times to reversal at the admitting hospital, less severe intracerebral hemorrhage, and lower odds of in‐hospital death versus direct‐admission patients after adjustment.

BackgroundA US survey of surgeons found that 32% store firearms unlocked and loaded. This study explored conditions and contexts impacting personal firearm storage methods among surgeons.MethodsWe conducted semi-structured interviews with English-speaking fellows of the American College of Surgeons who treated patients injured by firearms and who owned or lived in homes with firearms. Participants were recruited through email and subsequent snowball sampling from April 2022 to August 2022. All interviews were audio-recorded and transcribed verbatim. Thematic analysis was applied to transcripts to identify codes. A mixed deductive and inductive approach was used for data reduction and sorting.ResultsA total of 32 surgeons were interviewed; most were male and white. Dominant themes for firearm storage practices were based on (1) attitudes; (2) perceived norms; (3) personal agency; and (4) intention of firearm use. Personal agency often conflicted with attitudes and perceived norms for surgeons owning firearms for self-defence.ConclusionsStorage practices in this sample of firearm-owning surgeons were driven by intent for firearm use, coupled with attitudes, perceived norms and personal agency. Personal agency often conflicted with attitudes and perceived norms, especially for surgeons who owned their firearm for self-defence.

Abstract Background and aims Guidelines recommend rapid treatment of elevated systolic blood pressure (SBP) after intracerebral hemorrhage (ICH). However, contemporary real-world data linking early in-hospital SBP treatment to ICH outcomes are limited. Methods We performed a retrospective cohort analysis of the Hemorrhagic Stroke Data Layer of the American Heart Association Get With The Guidelines-Stroke US National Registry from February 8, 2023 to January 1, 2025. Exposures of interest included symptom onset to SBP treatment initiation (>2 hours vs ≤ 2 hours), and ED arrival to SBP treatment initiation (>1 hour vs ≤ 1 hour), among those with presenting SBP > 149 mmHg. Multivariable models using generalized estimating equations controlled for patient, admission, hospital characteristics, pre-stroke ambulatory status, antiplatelet and anticoagulant use, and stroke severity. The primary outcome was a composite of in-hospital mortality or discharge to hospice. Results 13,136 patients were included. Delayed SBP treatment was associated with worse discharge survival outcomes. Symptom onset to SBP treatment initiation > 2 hours (vs ≤ 2 hours) was associated with higher odds of inpatient mortality or discharge to hospice (aOR 1.16, 95% CI 1.05-1.29, n = 13,136). ED arrival to SBP treatment initiation > 1 hour (vs ≤ 1 hour) was associated with higher odds of inpatient mortality or discharge to hospice (aOR 1.21, 95% CI 1.08-1.36, n = 12,542). Associations with discharge disability measures were directionally inconsistent in some models, suggesting residual confounding. Conclusions In this national US stroke registry, delays to initiation of blood pressure-lowering treatment in patients with ICH were independently associated with higher odds of mortality and discharge to hospice, supporting the importance of rapid SBP treatment workflows for ICH. Conflict of interest Regina Royan, MD, MPH: Nothing to disclose. Brian Stamm, MD, MSc: Nothing to disclose. Raam Pravin: Nothing to disclose. James Cranford: Nothing to disclose. Mariama Runcie: Nothing to disclose. Adam De Havenon, MD: Dr. de Havenon received consulting fees from Novo Nordisk, author fees from UptoDate, and holds equity in Titin KM and Certus. Kori Zachrison, MD: Nothing to disclose. Steven Messe, MD: Dr. Messe holds a pending patent for the monitoring of upper limb movements to detect stroke and holds equity in Neuralert Technologies. Kevin Sheth, MD: Dr. Sheth received grants from the National Institutes of Health, American Heart Association, and Hyperfine; serves on the data safety monitoring board for Phillips and Sense; serves on the scientific advisory board for Astrocyte, BrainQ, Bexorg, and Rhaeos; holds equity in and a patent for Alva. Table 1 - belongs to Results

Importance:Telestroke has the potential to revolutionize acute stroke treatment by improving access to optimal stroke care, including time-sensitive care such as thrombolysis. However, it is unclear how treatment times and stroke outcomes compare between patients evaluated and not evaluated by telestroke. Objective:To evaluate the association between telestroke use and acute stroke treatment times and outcomes. Design, Setting, and Participants:This retrospective cohort study included patients with acute ischemic stroke aged 18 years or older presenting to 42 Paul Coverdell Michigan Stroke Registry hospitals from January 1, 2022, to December 31, 2023. All patients were potentially eligible for thrombolysis (ie, presented ≤4 hours of last known well, no contraindications to thrombolysis documented). Exposure:Telestroke (vs nontelestroke) encounter. Main Outcomes and Measures:The primary outcomes were receipt of thrombolysis and door-to-needle (DTN) time as a continuous variable and a categorical variable (≤60 vs >60 minutes). Secondary outcomes included discharge ambulatory status, discharge destination, and door-in-door-out (DIDO) time in transferred patients. Multivariable hierarchical models evaluated associations between telestroke (vs nontelestroke) activation and outcomes, sequentially adjusting for demographics, medical history, presentation or arrival, and hospital characteristics. Results:Among the 3036 patients with acute ischemic stroke potentially eligible for thrombolysis (mean [SD] age, 69.7 [14.5] years; 1563 male [51.5%]), 785 (25.9%) were evaluated using telestroke and 2251 (74.1%) without telestroke. A total of 1673 patients (55.1%) were treated with thrombolysis. In the fully adjusted models, patients evaluated by telestroke had a significantly higher odds of receiving thrombolysis (adjusted odds ratio, 1.61; 95% CI, 1.17-2.23) but longer DTN times (6.55 minutes longer; 95% CI, 2.12-10.97 minutes longer) and lower odds of meeting a guideline-concordant DTN time within 60 minutes (adjusted odds ratio, 0.56; 95% CI, 0.39-0.81) compared with those not evaluated by telestroke. Among 255 patients who underwent interhospital transfer, 207 (81.2%) received thrombolysis, and patients with telestroke had significantly longer DIDO times (46.90 minutes longer, 95% CI, 1.08-92.72 minutes longer). Conclusions and Relevance:In this cohort study of patients with acute ischemic stroke potentially eligible for thrombolysis, those evaluated by telestroke had a 61% higher odds of receiving thrombolysis but a 44% lower odds of meeting guideline-concordant DTN times within 60 minutes and prolonged DIDO times compared with those not evaluated by telestroke. Future research should investigate modifiable factors that contribute to treatment delays in patients with ischemic stroke evaluated via telestroke.

BACKGROUND:Pre-stroke ED visits may represent opportunities for stroke prevention. We evaluated the prevalence and predictors of ED visits in the 90-days preceding a stroke, and the frequency of visits for "high-risk" diagnoses known to be associated with short-term stroke risk, including neurologic symptoms, atrial fibrillation, falls, and hypertensive disorders. METHODS:Within an ongoing population-based stroke surveillance study in South Texas, we identified all physician-validated ischemic and hemorrhagic strokes from April 2003 to December 2020. Linked Medicare claims data were used to identify ED visits in the 90 days before each stroke. Logistic regression was used to evaluate clinical and sociodemographic factors associated with pre-stroke ED utilization. High risk diagnoses were identified by manual review. RESULTS:A total of 2498 validated stroke cases were matched to Medicare claims data. Patients were 57 % female and 47 % Mexican American with a mean age of 77 (SD 11). A total of 209 patients (8.4 %) had an ED visit in the 90-days before their stroke, including 102 (4.1 %) with multiple visits. Medicaid insurance (OR 1.54, 95 %CI 1.05-2.26) and diabetes (OR 1.73, 95 %CI 1.21-2.47) were associated with greater odds of a pre-stroke ED visit. Of 430 total ED visits, 87 (20.0 %) were for a high-risk diagnosis, including 70 (16.3 %) for a neurologic diagnosis, 12 (2.8 %) for a hypertensive disorder, and 5 (1.2 %) for atrial fibrillation. CONCLUSIONS:Pre-stroke ED visits were common, particularly among patients with diabetes or Medicaid insurance, and were often associated with high-risk primary diagnoses, potentially representing opportunities for stroke prevention or early treatment.

Introduction: Telestroke has the potential to revolutionize acute stroke treatment by improving access to optimal stroke care, including time-sensitive care such as thrombolysis. Yet few studies have compared acute stroke treatment metrics and outcomes in patients treated using telestroke versus standard in-person stroke evaluation. Methods: This was a retrospective cohort study of acute ischemic stroke patients age ≥18 presenting to 53 Paul Coverdell Michigan hospitals between 2022 and 2023 who were potentially eligible for thrombolysis (i.e., presented ≤ 4 hours of last known well, no contraindications to thrombolysis). The primary exposure was telestroke (vs non-telestroke), and primary outcomes were receipt of thrombolysis and door-to-needle (DTN) time. Secondary outcomes included discharge ambulatory status and door-in-door-out (DIDO) time in transferred patients. Multivariable hierarchical models evaluated associations between the telestroke (vs. non-telestroke) activation and outcomes, sequentially adjusted for demographics, medical history, presenting/arrival, and hospital characteristics. Results: Among the 4974 stroke patients potentially eligible for thrombolysis (mean age 69.2 [SD: 14.6], 48.3% female), 1078 (21.7%) were evaluated using telestroke and 3896 (78.3%) without telestroke. Telestroke patients were more commonly at primary stroke centers (71.1% vs 39.0%) and less at comprehensive stroke centers (13.3% vs 53.9%; P<0.001). Thrombolysis was administered to 56.8% of telestroke patients (at the site of telestroke initiation) versus 54.7% of patients without telestroke (P=0.23). Telestroke patients had longer DTN times (55 vs. 47 minutes, P<0.001), longer DIDO times (166 vs. 142 minutes, P<0.001), and a lower likelihood of ambulating independently at discharge (P<0.001). After adjusting for patient demographics, medical history, and presenting/arrival factors, telestroke patients had significantly longer DTN times (8.1 minutes longer, 95% CI 1.9, 14.3). This difference was attenuated after adjustment for hospital characteristics, including stroke center status. Discussion: Acute stroke treatment metrics, including DTN and DIDO times, were significantly worse in telestroke vs. non-telestroke cases from the Paul Coverdell Michigan stroke registry. Differences in DTN were partially explained by hospital-level systems factors, such as stroke center status, which may serve as targets for future studies and quality improvement initiatives.

Introduction: Novel therapies have changed the landscape of acute ischemic stroke (AIS) treatment over the past decade. Timely identification and treatment of AIS is imperative, which makes swift action by emergency departments (ED) critical. Most research on AIS comes from academic medical centers. We sought to report the temporal trends of ED-based AIS treatment from 2012-2022 in a community without an academic medical center. Methods: As part of the community-based Brain Attack Surveillance in Corpus Christi (BASIC) project, ischemic strokes treated in an emergency department were identified via active and passive surveillance. Logistic regression was used to model the temporal trends for overall neurology consult, tele-stroke consult, NIHSS documentation by provider, transfer to an out of area facility for mechanical thrombectomy, and tPA utilization. All predictions were adjusted for age, race/ethnicity, sex, NIHSS, and history of stroke/TIA. Mechanical thrombectomy candidates were also identified, and frequencies were calculated. Results: Sample size varied between 3912 and 5156 depending on the outcome and its number of observations with complete covariate data. NIHSS documentation by provider increased by 17.5% (95% CI: 0.135, 0.215) (Figure 1A). Overall neurology consultation rate increased by 25.6% (95% CI: 0.211, 0.302) (Figure 1B). Tele-stroke consult rate increased by 35.7% (95% CI: 0.307, 0.407) (Figure 1C). Patient transfer to an out of area facility for mechanical thrombectomy saw a peak around 2019 (3%) that subsequently declined by 2022 (0.2%) as this expertise became more available in the community (Figure 1D). tPA utilization increased by 6.7% (95% CI: 0.036, 0.098) (Figure 1E). The frequencies of mechanical thrombectomy in 2020, 2021, and 2022 were 2.00%, 4.14%, and 6.68% respectively. Conclusions: There have been remarkable changes in AIS treatment from the emergency medicine perspective in the last decade. Dramatic increases in neurology and tele-stroke consults, transfers for mechanical thrombectomy, and tPA usage suggests assertive treatment protocols in this “real-world” community without an academic medical center.

Importance:Firearm injury is a leading cause of mortality in the US. Contemporary firearm injury health care costs and characteristics of hospital visits can inform investment decisions on treatment and prevention strategies. Objective:To estimate the total health care cost of new firearm injury hospital visits from 2016 to 2021 in the US. Design, Setting, and Participants:This economic evaluation study via Monte Carlo simulation included data from the Arkansas, Florida, Maryland, Massachusetts, New York, and Wisconsin Healthcare Cost and Utilization Project State Inpatient and Emergency Department databases from 2016 to 2021. Children and adults with an inpatient or emergency department (ED) hospital visit for new firearm injuries were included. Data were analyzed from June 2023 to May 2025. Exposures:Firearm-related inpatient or ED visits with new firearm injury International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) diagnosis codes. Main Outcomes and Measures:A Monte Carlo simulation used new inpatient and ED firearm injury visits in 6 sample states to estimate the national health care cost for the treatment of initial firearm injuries from 2016 to 2021. The simulation also used national inpatient data from the RAND Corporation for nonsample states. Costs were adjusted for inflation to 2024 US dollars. Costs to each body region were derived from the Injury Mortality Diagnosis Matrix classification scheme. Results:The Monte Carlo analysis included 2400 simulations. Firearm injuries in the US led to an estimated 298 721 ED visits and 185 846 inpatient visits, with a total health care cost of $7.7 billion from 2016 to 2021. Inpatient admissions accounted for 93% of the cost, or $7.2 billion. Treatment for children younger than 18 years accounted for 9% of the cost, or $684 million. Annual ED and inpatient visits were both approximately stable from 2016 to 2019, at which point they grew by 42% and 40%, respectively, from 2019 to 2021. Annual total health care cost was also stable at approximately $1.2 billion until 2019, when cost began to grow to a peak of $1.6 billion in 2021. The mean (SE) ED visit cost was $1743 (4.5), and the mean (SE) inpatient admission cost was $38 879 (138.9). These costs remained stable annually over the sample period. Conclusions and Relevance:In this economic evaluation study, an increase in firearm injuries in the last 6 years paralleled an increase in costs from 2016 to 2021.

Background and Objectives Food deserts (FDs) are low-income areas with poor access to healthy foods. FD residents have higher rates of several cardiovascular risk factors, but the link between FDs and stroke has not been well studied. We evaluated whether FD residence was associated with incident ischemic stroke within the Greater Cincinnati/Northern Kentucky Stroke Study (GCNKSS) and whether this association was due to low income, poor food access, or both. Methods All hospitalized stroke cases in the GCNK region were ascertained during calendar year 2015 using ICD-9 and ICD-10 codes for screening and confirmed by physician review. Patient home addresses were geocoded using Decentralized Geomarker Assessment for Multi-Site Studies. FD locations were obtained from the US Department of Agriculture Food Access Research Atlas, defined as census tracts with both poor food access and low income according to established definitions based on proximity to healthy food sources as well as area poverty rates and median household income. Population estimates were obtained from the 2015 5-year American Community Survey. Poisson regression models were used to calculate census tract-level incidence rates by FD status, as well as by food access and income categories, adjusting for age, sex, race, and income-by-access interaction. Results A total of 1,802 first-ever ischemic stroke incidents occurred in the region during the study period. Stroke patients had a mean age of 69.7 years, and 53% were female. In unadjusted models, FD residence (vs non-FD) was associated with higher stroke incidence (incidence rate ratio [IRR] 1.23; 95% CI 1.06-1.42; p < 0.01). After adjustment for age, sex, and race, this relationship was attenuated and no longer statistically significant (IRR 1.11; 95% CI 0.96-1.30; p = 0.17). In a model where FD status was replaced by area income and food access (i.e., the 2 components of the FD definition), low income was associated with greater stroke incidence after full adjustment (IRR 1.21; 95% CI 1.05-1.39; p = 0.01) while poor food access was not (IRR 0.91; 95% CI 0.81-1.01; p = 0.08). Discussion FD residents are at increased stroke risk, and this is primarily due to low area income rather than poor food access. Alternative measures of the food environment may help elucidate the links between income, dietary patterns, and stroke risk.