Background and Purpose: Reversible cerebral vasoconstriction syndrome (RCVS) is a well-established cause of stroke, but its demographics and outcomes have not been well delineated. Methods: Analysis of the United States Nationwide Inpatient Sample database (2016–2017) to characterize the frequency of hospitalizations for RCVS, demographic features, inpatient mortality, and discharge outcomes. Results: During the 2-year study period, 2020 patients with RCVS were admitted to Nationwide Inpatient Sample hospitals, representing 0.02 cases per 100 000 national hospitalizations. The mean age at admission was 47.6 years, with 85% under 65 years of age, and 75.5% women. Concomitant neurological diagnoses during hospitalization included ischemic stroke (17.1%), intracerebral hemorrhage (11.0%), subarachnoid hemorrhage (32.7%), seizure disorders (6.7%), and reversible brain edema (13.6%). Overall, 70% of patients were discharged home, 29.7% discharged to a rehabilitation facility or nursing home and 0.3% died before discharge. Patient features independently associated with the poor outcome of discharge to another facility or death were advanced age (odds ratio [OR], 1.04 [95% CI, 1.03–1.04]), being a woman (OR, 2.45 [1.82–3.34]), intracerebral hemorrhage (OR, 2.91 [1.96–4.31]), ischemic stroke (OR, 5.72 [4.32–7.58]), seizure disorders (OR, 2.61 [1.70–4.00]), reversible brain edema (OR, 6.26 [4.41–8.89]), atrial fibrillation (OR, 2.97 [1.83–4.81]), and chronic kidney disease (OR, 3.43 [2.19–5.36]). Conclusions: Projected to the entire US population, >1000 patients with RCVS are hospitalized each year, with the majority being middle-aged women, and about 300 required at least some rehabilitation or nursing home care after discharge. RCVS-related inpatient mortality is rare.

Aim:To test the hypothesis that age-, sex-, and race and ethnicity-specific incidence of nontraumatic subarachnoid hemorrhage (SAH) increased in the United States (US) over the last decade.Methods:In this retrospective cohort study, validated International Classification of Diseases codes were used to identify all new cases of SAH (n = 39,475) in the State Inpatients Databases of New York and Florida (2007-2017). SAH counts were combined with Census data to calculate incidence. Joinpoint regression was used to compute the annual percentage change (APC) in incidence and to compare trends over time between demographic subgroups.Results:Across the study period, the average annual age/sex-standardized incidence of SAH in cases per 100,000 population was 11.4, but incidence was significantly higher in women (13.1) compared to men (9.6)p<0.001. Incidence also increased with age in both sexes (men 20-44 years: 3.6; men ≥65 years: 22.0). Age and sex-standardized incidence was greater in Black patients (15.4) compared to Non-Hispanic White (NHW) patients (9.9) and other races and ethnicities, p<0.001. On joinpoint regression, incidence increased over time (APC 0.7%, p <0.001) but most of this increase occurred in men 45-64 years (APC 1.1%,p=0.006), men ≥65 years (APC 2.3%, p<0.001) and women ≥65 years of age (APC 0.7%, p=0.009). Incidence in women 20-44 years declined (APC -0.7%, p=0.017), while those in other age/sex groups remained unchanged over time. Incidence increased in Black patients (APC 1.8%, p=0.014) while that in Asian, Hispanic, and NHW patients did not change significantly over time.Conclusion:Non-traumatic SAH incidence in the US increased over the last decade predominantly in middle-aged men and elderly men and women. Incidence is disproportionately higher and increasing in Black patients while that in other races and ethnicities did not change significantly over time.

Background: Despite the well-established potent benefit of mechanical thrombectomy (MT) for large vessel occlusion (LVO) stroke, access to MT has not been studied globally. We conducted a worldwide survey of countries on 6 continents to define MT access (MTA), the disparities in MTA, and its determinants on a global scale. Methods: Our survey was conducted in 75 countries through the Mission Thrombectomy 2020+ global network between November 22, 2020, and February 28, 2021. The primary end points were the current annual MTA, MT operator availability, and MT center availability. MTA was defined as the estimated proportion of patients with LVO receiving MT in a given region annually. The availability metrics were defined as ([current MT operators×50/current annual number of estimated thrombectomy-eligible LVOs]×100 = MT operator availability) and ([current MT centers×150/current annual number of estimated thrombectomy-eligible LVOs]×100= MT center availability). The metrics used optimal MT volume per operator as 50 and an optimal MT volume per center as 150. Multivariable-adjusted generalized linear models were used to evaluate factors associated with MTA. Results: We received 887 responses from 67 countries. The median global MTA was 2.79% (interquartile range, 0.70–11.74). MTA was <1.0% for 18 (27%) countries and 0 for 7 (10%) countries. There was a 460-fold disparity between the highest and lowest nonzero MTA regions and low-income countries had 88% lower MTA compared with high-income countries. The global MT operator availability was 16.5% of optimal and the MT center availability was 20.8% of optimal. On multivariable regression, country income level (low or lower–middle versus high: odds ratio, 0.08 [95% CI, 0.04–0.12]), MT operator availability (odds ratio, 3.35 [95% CI, 2.07–5.42]), MT center availability (odds ratio, 2.86 [95% CI, 1.84–4.48]), and presence of prehospital acute stroke bypass protocol (odds ratio, 4.00 [95% CI, 1.70–9.42]) were significantly associated with increased odds of MTA. Conclusions: Access to MT on a global level is extremely low, with enormous disparities between countries by income level. The significant determinants of MT access are the country’s per capita gross national income, prehospital LVO triage policy, and MT operator and center availability.

Objectives To evaluate current trends in the utilization of intravenous thrombolysis (IV-tPA) and mechanical thrombectomy (MT) in acute ischemic stroke (AIS) in various age groups of children in the United States. Methods We conducted a serial cross-sectional study using primary AIS admissions in children <=17years (weighted n =2807) contained in the 2009-2019 KIDS Inpatient Database. Age-specific utilization frequency of IV-tPA and MT were calculated. Multivariable-adjusted models were used to evaluate demographic predictors of treatment. Results From 2009-2019, there were 2,807 AIS admissions in children in the KID of which 55.9% were in boys and 29.9% were 15-17years old.128 (4.6%) received IV-tPA. IV-tPA utilization differed by age (5-9years: 3.1%, 15-17years 8.1% p-value <0.001). Overall MT usage was 2.3% and this also varied by age (1-4years: 0.9% and 15-17years 4.0%, p-=0.006). IV-tPA utilization almost tripled across the study period (2.5% 2009 to 6.5% in 2019, P-trend 0.001) while MT use more than doubled over time (1.2% in 2009 and 3.0% in 2019, p-trend 0.048). Increased IV-tPA utilization was seen primarily in children 10- 14years (0.8% in 2009 to 7.2% 2019, P-trend =0.005] and 15-17years (5.4% in 2009 to 10.4% in 2019, p-trend 0.045]. Utilization in younger age groups remained unchanged over time. MT usage was very variable across various age groups over time. IV-tPA and MT utilization increased over time in non-children’s hospitals (both p-values <0.05) but usage in designated children’s hospitals did not change significantly over time. In multivariable models, there was no significant difference in odds of IV-tPA and MT use by sex, race or insurance status. Conclusion IV-tPA and MT utilization in pediatric AIS increased in the US over the last decade mainly in older children 10-17years. Utilization increased mainly in patients hospitalized in non-children’s hospitals. Usage in children’s hospitals did not change significantly over time.

BACKGROUND: The incidence of cerebral venous thrombosis (CVT) in children of the United States is unknown, and it is uncertain how the burden of CVT hospitalizations in children changed over the last decade. METHODS: We conducted a retrospective cohort study using the State Inpatient Database and Kid’s inpatient database. All new CVT cases in children (0–19 years) in the New York 2006 to 2018 State Inpatient Database (n=705), and all cases of CVT in the entire US contained in the 2006 to 2019 Kid’s inpatient database (weighted n=6115) were identified using validated International Classification of Diseases (ICDs ) codes. Incident counts were combined with census data to compute incidence. Between-group differences in incidence were tested using 2-proportions Z -test, and Joinpoint regression was used to trend incidence over time. RESULTS: Across the study period, 48.2% of all incident CVT cases and 44.6% of all CVT admissions nationally were in girls. Of all incident cases, 27.2% were infants and 65.8% of these infants were neonates. Average incidence across the study period was (1.1/100 000/year, SE:0.04) but incidence in infants (6.4/100 000/year) was at least 5 times the incidence in other age groups (1–4 years: 0.7/100 000/year, 15–19 years: 1.2/100 000/year). Incidence and national burden of CVT admissions was higher in girls in adolescents 15 to 19 years, but overall burden was higher in boys in other age groups. Age- and sex-standardized CVT incidence increased by 3.8% annually (95% CI, 0.2%–7.6%), while the overall burden of admissions increased by 4.9% annually (95% CI, 3.6%–6.2%). CONCLUSIONS: CVT incidence in New York and national burden of CVT increased significantly over the last decade.

Background and Objectives:In the United States, Black, Hispanic, and Asian Americans suffer from excessively high incidence rates of hemorrhagic stroke compared to White Americans. Women suffer from higher rates of subarachnoid hemorrhage than men. Previous reviews detailing racial, ethnic, and sex disparities in stroke have focused on ischemic stroke. We performed a scoping review of disparities in the diagnosis and management of hemorrhagic stroke in the United States to identify areas of disparities, research gaps, and evidence to inform efforts aimed at health equity.Methods:We included studies published after 2010 that assessed racial and ethnic or sex disparities in the diagnosis or management of patients 18 years or older in the United States with a primary diagnosis of spontaneous intracerebral hemorrhage or aneurysmal subarachnoid hemorrhage. We did not include studies assessing disparities in incidence, risks, or mortality and functional outcomes of hemorrhagic stroke.Results:After reviewing 6161 abstracts and 441 full texts, 59 studies met our inclusion criteria. Four themes emerged. First, few data address disparities in acute hemorrhagic stroke. Second, racial and ethnic disparities in blood pressure control following intracerebral hemorrhage exist and likely contribute to disparities in recurrence rates. Third, racial and ethnic differences in end-of-life-care exist, but further work is required to understand whether these differences represent true disparities in care. Fourth, very few studies specifically address sex disparities in hemorrhagic stroke care.Discussion:Further efforts are necessary to delineate and correct racial, ethnic, and sex disparities in the diagnosis and management of hemorrhagic stroke.

Objective:To test the hypothesis that the age and sex-specific prevalence of infectious [pneumonia, sepsis, and urinary tract infection (UTI)] and non-infectious [deep venous thrombosis (DVT), pulmonary embolism (PE), acute renal failure (ARF), acute myocardial infarction (AMI), gastrointestinal bleeding (GIB)] complications increased following acute ischemic stroke (AIS) hospitalization in the United States (US) from 2007- 2019.Methods:We conducted a serial cross-sectional study using the 2007-2019 National Inpatient Sample. Primary AIS admissions in adults (≥18 years) with and without complications were identified using International Classification of Diseases Codes. We quantified the age/sex-specific prevalence of complications and used negative binomial regression models to evaluate trends over time.Results:Of 5,751,601 weighted admissions, 51.4% were women. 25.1% had at least one complication. UTI (11.8%), ARF (10.1%), pneumonia (3.2%) and AMI (2.5%) were the most common complications, while sepsis (1.7%), GIB (1.1%), DVT (1.2%), and PE (0.5%) were the least prevalent. Marked disparity in complication risk existed by age/sex (UTI: men 18-39 years 2.1%; women ≥80 years 22.5%). Prevalence of UTI (12.9% to 9.7%) and pneumonia (3.8% to 2.7%) declined, but that of ARF increased by ≈3-fold (4.8% to 14%) over the period 2007-2019, (allp<0.001). AMI (1.9% to 3.1%), DVT (1.0% to 1.4%), and PE (0.3% to 0.8%) prevalence also increased (p<0.001), but that of sepsis and GIB remained unchanged over time. After multivariable adjustment, risk of all complications increased with increasing National Institute of Health Stroke Scale (Pneumonia, prevalence rate ratio [PRR] 1.03, 95%CI 1.03-1.04, for each unit increase), but intravenous thrombolysis was associated with reduced risk of all complications (pneumonia: PRR 0.80, 85%CI 0.73-0.88; AMI: PRR 0.85, 95%CI 0.78-0.92; DVT PRR 0.87, 95%CI 0.78-0.98). Mechanical thrombectomy was associated with reduced risk of UTI, sepsis, and ARF but DVT and PE were more prevalent in MT hospitalizations compared to those without. All complications except UTI were associated with increased risk of in-hospital mortality (sepsis: PRR 1.97, 95%CI 1.78-2.19).Conclusion:Infectious complications declined, but noninfectious complications, increased following AIS admissions in the US in the last decade. Utilization of intravenous thrombolysis is associated with reduced risk of all complications.

Background:To estimate age, sex and race-specific incidence of posterior reversible encephalopathy syndrome (PRES) in the United States.Methods:We conducted a retrospective cohort study using the State Inpatient Database of Florida (2016-2019), Maryland (2016-2019) and New York (2016-2018). All new cases of PRES in adults (≥18 years) were combined with Census data to compute incidence. We evaluated the generalizability of incident estimates to the entire country using the 2016-2019 National Readmissions Database (NRD).Results:Across the study period, there were 3,716 incident hospitalizations for PRES in the selected states. The age and sex-standardized incidence of PRES was 2.7 (95% CI 2.5-2.8) cases/100,000/year. Incidence in female patients was >2-times that of male patients (3.7 vs 1.6 cases/100,000/year,p<0.001). Incidence increased with age in both sexes (p-trend <0.001). Similar demographic distribution of first hospitalization for PRES was also noted in the entire country using the NRD. Age and sex-standardized PRES incidence in Black patients (4.2/100,000/year) was significantly greater than in Non-Hispanic White (2.7/100,000/year) and Hispanic patients (1.2/100,000/year) (p<0.001 for pairwise comparisons).Conclusion:The incidence of PRES in the US is approximately 3/100,000/year but incidence in female patients is >two-times that of male patients. PRES incidence is higher in Black compared to Non-Hispanic White and Hispanic patients.