Obstructive sleep apnea (OSA) is characterized by recurrent complete and partial upper airway obstructive events, resulting in intermittent hypoxemia, autonomic fluctuation, and sleep fragmentation. Approximately 34% and 17% of middle-aged men and women, respectively, meet the diagnostic criteria for OSA. Sleep disturbances are common and underdiagnosed among middle-aged and older adults, and the prevalence varies by race/ethnicity, sex, and obesity status. OSA prevalence is as high as 40% to 80% in patients with hypertension, heart failure, coronary artery disease, pulmonary hypertension, atrial fibrillation, and stroke. Despite its high prevalence in patients with heart disease and the vulnerability of cardiac patients to OSA-related stressors and adverse cardiovascular outcomes, OSA is often underrecognized and undertreated in cardiovascular practice. We recommend screening for OSA in patients with resistant/poorly controlled hypertension, pulmonary hypertension, and recurrent atrial fibrillation after either cardioversion or ablation. In patients with New York Heart Association class II to IV heart failure and suspicion of sleep-disordered breathing or excessive daytime sleepiness, a formal sleep assessment is reasonable. In patients with tachy-brady syndrome or ventricular tachycardia or survivors of sudden cardiac death in whom sleep apnea is suspected after a comprehensive sleep assessment, evaluation for sleep apnea should be considered. After stroke, clinical equipoise exists with respect to screening and treatment. Patients with nocturnally occurring angina, myocardial infarction, arrhythmias, or appropriate shocks from implanted cardioverter-defibrillators may be especially likely to have comorbid sleep apnea. All patients with OSA should be considered for treatment, including behavioral modifications and weight loss as indicated. Continuous positive airway pressure should be offered to patients with severe OSA, whereas oral appliances can be considered for those with mild to moderate OSA or for continuous positive airway pressure–intolerant patients. Follow-up sleep testing should be performed to assess the effectiveness of treatment.

Intracerebral hemorrhage (ICH) is the stroke subtype with the worst prognosis and has no established acute treatment. ICH is classified as lobar or nonlobar based on the location of ruptured blood vessels within the brain. These different locations also signal different underlying vascular pathologies. Heritability estimates indicate a substantial genetic contribution to risk of ICH in both locations. We report a genome-wide association study of this condition that meta-analyzed data from six studies that enrolled individuals of European ancestry. Case subjects were ascertained by neurologists blinded to genotype data and classified as lobar or nonlobar based on brain computed tomography. ICH-free control subjects were sampled from ambulatory clinics or random digit dialing. Replication of signals identified in the discovery cohort with p < 1 × 10(-6) was pursued in an independent multiethnic sample utilizing both direct and genome-wide genotyping. The discovery phase included a case cohort of 1,545 individuals (664 lobar and 881 nonlobar cases) and a control cohort of 1,481 individuals and identified two susceptibility loci: for lobar ICH, chromosomal region 12q21.1 (rs11179580, odds ratio [OR] = 1.56, p = 7.0 × 10(-8)); and for nonlobar ICH, chromosomal region 1q22 (rs2984613, OR = 1.44, p = 1.6 × 10(-8)). The replication included a case cohort of 1,681 individuals (484 lobar and 1,194 nonlobar cases) and a control cohort of 2,261 individuals and corroborated the association for 1q22 (p = 6.5 × 10(-4); meta-analysis p = 2.2 × 10(-10)) but not for 12q21.1 (p = 0.55; meta-analysis p = 2.6 × 10(-5)). These results demonstrate biological heterogeneity across ICH subtypes and highlight the importance of ascertaining ICH cases accordingly.

Objective: To estimate the ability of bedside information to risk stratify stroke in acute dizziness presentations.Methods: Surveillance methods were used to identify patients with acute dizziness and nystagmus or imbalance, excluding those with benign paroxysmal positional vertigo, medical causes, or moderate to severe neurologic deficits. Stroke was defined as acute infarction or intracerebral hemorrhage on a clinical or research MRI performed within 14 days of dizziness onset. Bedside information comprised history of stroke, the ABCD 2 score (age, blood pressure, clinical features, duration, and diabetes), an ocular motor (OM)-based assessment (head impulse test, nystagmus pattern [central vs other], test of skew), and a general neurologic examination for other CNS features. Multivariable logistic regression was used to determine the association of the bedside information with stroke. Model calibration was assessed using low (,5%), intermediate (5% to ,10%), and high ($10%) predicted probability risk categories. 05-4.57). No stroke cases were in the model's low-risk probability category (0/86, 0%), whereas 9 were in the moderate-risk category (9/94, 9.6%) and 20 were in the high-risk category (20/92, 21.7%). Results Conclusion:In acute dizziness presentations, the combination of ABCD 2 score, general neurologic examination, and a specialized OM examination has the capacity to risk-stratify acute stroke on MRI. Neurology ® 2015;85:1869-1878 GLOSSARY ABCD 2 5 age, blood pressure, clinical features, duration, diabetes; CI 5 confidence interval; HINTS 5 head impulse, nystagmus pattern, test of skew; HIT 5 head impulse test; ICH 5 intracerebral hemorrhage; OM 5 ocular motor; OR 5 odds ratio.Patients with dizziness from stroke are challenging to identify because they often lack typical stroke warning signs or symptoms. [1][2][3][4][5][6] Prior studies have been performed to assess bedside decision support tools that could help to discriminate stroke from other causes of acute dizziness.3,4,7 The ABCD 2 score (age, blood pressure, clinical features, duration, and diabetes) may also be useful in discriminating vascular from nonvascular events. [8][9][10] When assessed in a retrospective study of emergency department dizziness presentations, the visits with a low-risk ABCD 2 score (ABCD 2 , 4) had a stroke frequency of 1% (5/512 patients) compared with 8.1% (32/395) in the high-risk group (ABCD 2 $ 4). 3 Another tool that has been developed to identify cases of dizziness-stroke is the HINTS assessment (head impulse, nystagmus pattern, test of skew), which is based on a specialty bedside ocular motor (OM) examination.4 HINTS has shown promising results, superior to the ABCD 2 score (sensitivity/ specificity: ABCD 2 , 61%/62%; HINTS, 96.5%/84.4%) in a prospective study of acute dizziness. 4 In this study, we expand on this prior work by evaluating the ability of the combination of bedside predictors of stroke-including both the ABCD 2 score and the specialized OM examination-to stratify stroke risk using an MR...

Neurologists are seldom involved with acute cerebrovascular care in the emergency department (ED), especially in patients with TIA. Greater neurologist involvement may improve acute stroke diagnosis and treatment efforts in the ED.