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BACKGROUND AND PURPOSE Organized systems of care have the potential to improve acute stroke care delivery. The current report describes the experience of implementing a countywide system of spoke-and-hub Stroke Neurology Receiving Centers (SNRC) that incorporated several comprehensive stroke center recommendations. METHODS Observational study of patients with suspected stroke <5 hours duration transported by Emergency Medical System personnel to an SNRC during the first year of this system. RESULTS A total of 1,360 patients with suspected stroke were evaluated at 9 hub SNRCs, of which 553 (40.7%) had a discharge diagnosis of ischemic stroke. Of these 553, intravenous (IV) tPA was given to 110 patients (19.9% of ischemic strokes). Care at the 6 neurointerventional-ready SNRC was a major focus, where 25.1% (99/395) of the patients with ischemic stroke received acute IV or intraarterial reperfusion therapy, and where provision of such therapies was less common with milder stroke, higher age, and Hispanic origin. The door-to-needle time for IV tPA met the <60 minute target in only 25% of patients and was 37% longer (p=0.0001) when SNRCs were neurointerventional-ready. CONCLUSIONS A stroke system that incorporates features of comprehensive stroke centers can be effectively implemented, and with substantial rates of acute reperfusion therapy administration. Experiences potentially useful to broader implementation of comprehensive stroke centers are considered.

Methamphetamine use has emerged as a risk factor for intracerebral hemorrhage (ICH). We aim to investigate the clinical characteristics and outcomes of methamphetamine-associated ICH (Meth-ICH) versus Non-Meth-ICH. Patients with ICH between January 2011 and December 2017 were studied. Meth-ICH and Non-Meth-ICH were defined by history of abuse and urine drug screen (UDS). The clinical features of the 2 groups were explored. Among the 677 consecutive patients, 61 (9.0%) were identified as Meth-ICH and 350 as Non-Meth ICH. Meth-ICH was more common in Hispanics (14.6%) and Whites (10.1%) as compared to Asians (1.2%). Patients with Meth-ICH were more often younger (51.2 vs. 62.2 years, p < 0.001), male (77.0% vs. 61.4.0%, p < 0.05), and smokers (44.3% vs. 13.4%, p < 0.001). Non-Meth-ICH was more likely to have history of hypertension (72.61% v. 59%, p < 0.05) or antithrombotic use (10.9% vs. 1.6%, p < 0.05). There was no significant difference in clinical severity, hospital length of stay (LOS), rate of functional independence (29.5% vs. 25.7%, p = 0.534), or mortality (18.0% vs. 24.6%, p = 0.267) between the 2 groups. Methamphetamine use was not an independent predictor of poor outcome. Despite difference in demographics, Meth-ICH is similar to Non-Meth ICH in hospital course and outcome. MethodsThis is a retrospective observational study. It was approved by the University of California Irvine Institutional Review Board (IRB) and the Ethics Committee. Informed consents were waived as part of the IRB approval. All methods in the study were performed in accordance with the relevant guidelines and regulations.Consecutive patients with spontaneous ICH at the University of California Irvine Comprehensive Stroke Center between January 1, 2011 and December 31, 2017 were identified by searching electronic medical records and the prospectively maintained American Heart Association (AHA)-Get With The Guidelines (GWTG)-Stroke Registry. ICH from cerebral aneurysm, arteriovenous malformation, brain tumors, coagulopathy, or trauma were excluded. Patients with Meth-ICH were identified by recorded history of methamphetamine use or a positive urine drug screen (UDS) at the time of admission. The UDS was performed using EMIT II Plus Amphetamines assay (1,000 ng/mL cutoff) with a sensitivity and specificity of 94.3% and 93.3%, respectively 21 . Those with a positive UDS while taking trazodone, Adderall, bupropion, or labetalol within 2 weeks of admission were excluded due to potential false-positive result 22 . Patients with no history of methamphetamine use and a negative UDS were included in Non-Meth-ICH group. Patients who denied history of drug abuse but had no UDS were excluded from the comparison analysis. All ICH patients were initially managed in the dedicated Neuroscience ICU with standard ICH order-set and clinical pathway by board-certified neurointensivists.The following information was abstracted from chart review and the AHA GWTG-Stroke Registry: age, gender, race, past medical history, the highest blood pressure (BP) lev...

Background and Purpose The current study aimed to identify predictors of acute mortality after intracerebral hemorrhage (ICH), including voxel-wise analysis of hematoma location. Methods In 282 consecutive patients with acute ICH, clinical and radiological predictors of acute mortality were identified. Voxel-based lesion-symptom mapping examined spatial correlates of acute mortality, contrasting results in basal ganglia ICH and lobar ICH. Results Acute mortality was 47.9%. In bivariate analyses, one clinical (serum glucose) and two radiological (hematoma volume and intraventricular extension) measures significantly predicted mortality. The relationship was strongest for hematoma volume. Multivariable modeling identified four significant predictors of mortality (ICH volume, intraventricular extension, serum glucose, and serum hemoglobin), although this model only minimally improved the predictive value provided by ICH volume alone. Voxel-wise analysis found that for patients with lobar ICH, brain regions where acute hematoma was significantly associated with higher acute mortality included inferior parietal lobule and posterior insula; for patients with basal ganglia ICH, a large region extending from cortex to brainstem. Conclusions For patients with lobar ICH, acute mortality is related to both hematoma size and location, with findings potentially useful for therapeutic decision-making. The current findings also underscore differences between the syndromes of acute deep and lobar ICH.

BackgroundHypertension (HTN) is the most common cause of spontaneous intracerebral hemorrhage (ICH). The aim of this study is to investigate the role of resistant HTN in patients with ICH.Methods and resultsWe conducted a retrospective study of all consecutive ICH admissions at our medical center from November 2013 to October 2015. The clinical features of patients with resistant HTN (requiring four or more antihypertensive agents to keep systolic blood pressure <140 mm Hg) were compared with those with responsive HTN (requiring three or fewer agents). Of the 152 patients with hypertensive ICH, 48 (31.6%) had resistant HTN. Resistant HTN was independently associated with higher body mass index and proteinuria. Compared to the responsive group, patients with resistant HTN had higher initial blood pressures and greater requirement for ventilator support, hematoma evacuation, hypertonic saline therapy, and nicardipine infusion. Resistant HTN increases length of stay (LOS) in the intensive care unit (ICU) (4.2 vs 2.1 days; p = 0.007) and in the hospital (11.5 vs 7.0 days; p = 0.003). Multivariate regression analysis showed that the rate of systolic blood pressure >140 mm Hg and duration of nicardipine infusion were independently associated with LOS in the ICU. There was no significant difference in hematoma expansion and functional outcome at hospital discharge between the two groups.ConclusionResistant HTN in patients with ICH is associated with more medical interventions and longer LOS without effecting outcome at hospital discharge.

Favorable features of this acute stroke care system include reperfusion therapy in 29.2% of patients with ischemic stroke and substantial increases in endovascular treatment rates over time. Continued efforts to optimize acute stroke systems of care can be directed toward improving access to best acute stroke therapies.

Susceptibility-weighted imaging (SWI) is commonly used to diagnose cerebral hemorrhage, calcification, and other T2* lesions. Its role in the detection of cerebral thromboemboli has been suggested for emboli of the anterior division of the middle cerebral artery (MCA). The purpose of our study was to determine SWI's accuracy and sensitivity in detection of all sites of cerebral thromboemboli, not just MCA emboli. Two neuroradiologists retrospectively reviewed consecutive MRI brain examinations with SWI for cerebral thromboemboli in 100 patients with clinical suspicion for stroke determined by the NIH Stroke Scale (NIHSS) score. FLAIR, MRA, CT, and catheter angiography were reviewed for thromboemboli in the same patients. Thromboembolic sites included: the internal carotid artery (ICA) terminus, anterior MCA, posterior MCA, any other cerebral artery, or if not present. The exclusion criteria included: no magnetic resonance angiogram (MRA) or catheter angiogram for comparison, lack of restricted diffusion, lacunar infarcts, and the presence of massive hemorrhage. The accuracy, sensitivity, and specificity of each imaging modality were determined. Twenty-four patients were excluded based on the aforementioned criteria. Cerebral thromboemboli were identified in 35 of the remaining 76 patients. Of the 35 patients with thromboemboli, 30 were identified on SWI. FLAIR detected 22/35 emboli, MRA 30/33, CT 18/35, and catheter angiography 12/12. The accuracies for SWI, FLAIR, and CT were 97%, 84%, and 74%, respectively. The sensitivities for SWI, FLAIR, and CT were 85%, 61%, and 52%, respectively. The specificities for SWI, FLAIR, and CT were 100%, 98%, and 93%, respectively. There is an adjunctive role of SWI to identify cerebral thromboemboli in patients with acute infarction. SWI is superior to FLAIR and CT, and complementary to MRA and catheter angiography in emboli detection. This study supports SWI detection of MCA emboli, but also emphasizes its utility in emboli detection of other arteries based on a high accuracy and sensitivity.

Methamphetamine use causes spikes in blood pressure. Chronic hypertension is a major risk factor for cerebral small vessel disease (cSVD). The aim of this study is to investigate whether methamphetamine use increases the risk of cSVD. Consecutive patients with acute ischemic stroke at our medical center were screened for methamphetamine use and evidence of cSVD on MRI of the brain. Methamphetamine use was identified by self-reported history and/or positive urine drug screen. Propensity score matching was used to select non-methamphetamine controls. Sensitivity analysis was performed to assess the effect of methamphetamine use on cSVD. Among 1369 eligible patients, 61 (4.5%) were identified to have a history of methamphetamine use and/or positive urine drug screen. Compared with the non-methamphetamine group (n = 1306), the patients with methamphetamine abuse were significantly younger (54.5 ± 9.7 vs. 70.5 ± 12.4, p < 0.001), male (78.7% vs. 54.0%, p < 0.001) and White (78.7% vs. 50.4%, p < 0.001). Sensitivity analysis showed that methamphetamine use was associated with increased white matter hyperintensities, lacunes, and total burden of cSVD. The association was independent of age, sex, concomitant cocaine use, hyperlipidemia, acute hypertension, and stroke severity. Our findings suggest that methamphetamine use increases the risk of cSVD in young patients with acute ischemic stroke.