Spontaneous intracranial artery dissection is an uncommon and probably underdiagnosed cause of stroke that is defi ned by the occurrence of a haematoma in the wall of an intracranial artery. Patients can present with headache, ischaemic stroke, subarachnoid haemorrhage, or symptoms associated with mass eff ect, mostly on the brainstem. Although intracranial artery dissection is less common than cervical artery dissection in adults of European ethnic origin, intracranial artery dissection is reportedly more common in children and in Asian populations. Risk factors and mechanisms are poorly understood, and diagnosis is challenging because characteristic imaging features can be diffi cult to detect in view of the small size of intracranial arteries. Therefore, multimodal follow-up imaging is often needed to confi rm the diagnosis. Treatment of intracranial artery dissections is empirical in the absence of data from randomised controlled trials. Most patients with subarachnoid haemorrhage undergo surgical or endovascular treatment to prevent rebleeding, whereas patients with intracranial artery dissection and cerebral ischaemia are treated with antithrombotics. Prognosis seems worse in patients with subarachnoid haemorrhage than in those without.

e3T elestroke is one of the most successful applications of telemedicine, bringing the experience of stroke experts to hospitals lacking appropriate stroke expertise. The number and extent of telestroke networks continue to grow in the United States and throughout the world. As telestroke matures, monitoring practice quality and outcomes becomes essential to Purpose-Telestroke is one of the most frequently used and rapidly expanding applications of telemedicine, delivering much-needed stroke expertise to hospitals and patients. This document reviews the current status of telestroke and suggests measures for ongoing quality and outcome monitoring to improve performance and to enhance delivery of care. Methods-A literature search was undertaken to examine the current status of telestroke and relevant quality indicators.The members of the writing committee contributed to the review of specific quality and outcome measures with specific suggestions for metrics in telestroke networks. The drafts were circulated and revised by all committee members, and suggestions were discussed for consensus. Results-Models of telestroke and the role of telestroke in stroke systems of care are reviewed. A brief description of the science of quality monitoring and prior experience in quality measures for stroke is provided. Process measures, outcomes, tissue-type plasminogen activator use, patient and provider satisfaction, and telestroke technology are reviewed, and suggestions are provided for quality metrics. Additional topics include licensing, credentialing, training, and documentation. (Stroke. 2017;48:e3-e25.

Cervical artery dissection (CeAD), a mural hematoma in a carotid or vertebral artery, is a major cause of ischemic stroke in young adults although relatively uncommon in the general population (incidence of 2.6/100,000 per year)1. Minor cervical traumas, infection, migraine and hypertension are putative risk factors1–3, and inverse associations with obesity and hypercholesterolemia are described3,4. No confirmed genetic susceptibility factors have been identified using candidate gene approaches5. We performed genome-wide association studies (GWAS) in 1,393 CeAD cases and 14,416 controls. The rs9349379[G] allele (PHACTR1) was associated with lower CeAD risk (odds ratio (OR) = 0.75, 95% confidence interval (CI) = 0.69–0.82; P = 4.46 × 10−10), with confirmation in independent follow-up samples (659 CeAD cases and 2,648 controls; P = 3.91 × 10−3; combined P = 1.00 × 10−11). The rs9349379[G] allele was previously shown to be associated with lower risk of migraine and increased risk of myocardial infarction6–9. Deciphering the mechanisms underlying this pleiotropy might provide important information on the biological underpinnings of these disabling conditions.

Background Data on the association between air pollution and cerebrovascular disease in the US are limited. The objective of this study was to investigate the association between short-term exposure to ambient air pollution and risk of ischemic cerebrovascular events in a US community. Methods Daily counts of ischemic strokes/TIAs (2001–2005) were obtained from the population-based Brain Attack Surveillance in Corpus Christi (BASIC) Project. Daily particulate matter <2.5μm in diameter (PM2.5), ozone (O3), and meteorological data were obtained from Texas Commission on Environmental Quality. To examine the association between PM2.5 and stroke/TIA risk, Poisson regression was used. Separate models included same day PM2.5, PM2.5 lagged 1–5 days, and an averaged lag effect. All models were adjusted for temperature, day of week and temporal trends in stroke/TIA. The effects of O3 were also investigated. Results Median PM2.5 was 7.0 μg/m3 (Inter Quartile Range (IQR): 4.8–10.0). There were borderline significant associations between same day (RR=1.03, 95% CI:0.99–1.07 for an IQR increase in PM2.5) and previous day (RR=1.03, 95% CI:1.00–1.07) PM2.5 and stroke/TIA risk. These associations were independent of O3, which demonstrated similar associations with stroke/TIA risk (same day RR=1.02, 95% CI: 0.97–1.08 and previous day RR=1.04, 95% CI: 0.99–1.09) in two pollutant models. Inference We observed associations between recent PM2.5 and O3 exposure and ischemic stroke/TIA risk even in this community with relatively low pollutant levels. This study provides data on environmental exposures and stroke risk in the US and suggests future research on ambient air pollution and stroke is warranted.

Objective: To conduct a cost-effectiveness analysis of telestroke-a 2-way, audiovisual technology that links stroke specialists to remote emergency department physicians and their stroke patients-compared to usual care (i.e., remote emergency departments without telestroke consultation or stroke experts). Methods:A decision-analytic model was developed for both 90-day and lifetime horizons. Model inputs were taken from published literature where available and supplemented with western states' telestroke experiences. Costs were gathered using a societal perspective and converted to 2008 US dollars. Quality-adjusted life-years (QALYs) gained were combined with costs to generate incremental cost-effectiveness ratios (ICERs). In the lifetime horizon model, both costs and QALYs were discounted at 3% annually. Both one-way sensitivity analyses and Monte Carlo simulations were performed. Results:In the base case analysis, compared to usual care, telestroke results in an ICER of $108,363/QALY in the 90-day horizon and $2,449/QALY in the lifetime horizon. For the 90-day and lifetime horizons, 37.5% and 99.7% of 10,000 Monte Carlo simulations yielded ICERs Ͻ$50,000/QALY, a ratio commonly considered acceptable in the United States.

Ischemic stroke prompts a strong inflammatory response, which is associated with exacerbated outcomes. In this study, we investigated mechanistic regulators of neutrophil extracellular trap (NET) formation in stroke and whether they contribute to stroke outcomes. NET-forming neutrophils were found throughout brain tissue of ischemic stroke patients, and elevated plasma NET biomarkers correlated with worse stroke outcomes. Additionally, we observed increased plasma and platelet surface–expressed high-mobility group box 1 (HMGB1) in stroke patients. Mechanistically, platelets were identified as the critical source of HMGB1 that caused NETs in the acute phase of stroke. Depletion of platelets or platelet-specific knockout of HMGB1 significantly reduced plasma HMGB1 and NET levels after stroke, and greatly improved stroke outcomes. We subsequently investigated the therapeutic potential of neonatal NET-inhibitory factor (nNIF) in stroke. Mice treated with nNIF had smaller brain infarcts, improved long-term neurological and motor function, and enhanced survival after stroke. nNIF specifically blocked NET formation without affecting neutrophil recruitment after stroke. Importantly, nNIF also improved stroke outcomes in diabetic and aged mice and was still effective when given 1 hour after stroke onset. These results support a pathological role for NETs in ischemic stroke and warrant further investigation of nNIF for stroke therapy.

Increased blood pressure variability as measured by the SD, CV, and SV consistently predict worse neurologic outcomes as measured by follow-up mRS in patients with ischemic stroke treated with intra-arterial therapies. The SV is the strongest and most consistent predictor of worse outcomes at all time intervals.

The coronavirus 2019 (COVID-19) pandemic requires drastic changes in allocation of resources, which can affect the delivery of stroke care, and many providers are seeking guidance. As caregivers, we are guided by 3 distinct principles that will occasionally conflict during the pandemic: (1) we must ensure the best care for those stricken with COVID-19, (2) we must provide excellent care and advocacy for patients with cerebrovascular disease and their families, and (3) we must advocate for the safety of health care personnel managing patients with stroke, with particular attention to those most vulnerable, including trainees. This descriptive review by a diverse group of experts in stroke care aims to provide advice by specifically addressing the potential impact of this pandemic on (1) the quality of the stroke care delivered, (2) ethical considerations in stroke care, (3) safety and logistic issues for providers of patients with stroke, and (4) stroke research. Our recommendations on these issues represent our best opinions given the available information, but are subject to revision as the situation related to the COVID-19 pandemic continues to evolve. We expect that ongoing emergent research will offer additional insights that will provide evidence that could prompt the modification or removal of some of these recommendations.