Recognizing the potential over response by employees who have headaches, our study remains suggestive of a care improvement opportunity in the health care workforce.

A majority of stroke research in the United States focuses on Caucasian and African-American populations, limiting the amount of comparative stroke data available on other racial and ethnic groups. The purpose of this research was to examine differences in stroke risk factors/subtypes between minority stroke patient groups in the United States (Asian-Indian, African-American, and Hispanic), using a Caucasian reference group. All patients had a comprehensive stroke work-up to ascertain their stroke risk factors and their stroke etiology applying TOAST criteria. Minority groups were younger compared with the white stroke patients, with the mean age significantly lower in the Asian-Indian and the Hispanic groups. The male:female ratio favored males in the Asian-Indian and Hispanic subgroups and females in the Caucasian and African-American groups. Diabetes was more prevalent in the minority subgroups, with a highest prevalence (55%) noted in the Asian-Indian group. The minority groups had lower prevalence of atrial fibrillation, carotid stenosis (≥70%), CAD, PVD, smoking, and alcohol use. The Asian-Indian stroke group had a higher median fasting plasma homocysteine level compared with the reference white group (12.1 vs. 10.4, p = 0.002). Compared to the reference white stroke group, the Asian-Indian stroke group had fewer strokes related to cardioembolism (7% vs. 25%) and a higher number of strokes related to small vessel occlusive disease (25% vs. 11%). There are some similarities in the stroke risk factors between the minority stroke groups, but the data indicate that there are different trends in stroke risk factors and subtypes.

Background Acute stroke teams are challenged by IV-tPA decision making in patients with acute neurological symptoms when the diagnosis is unclear. The purpose of this study was to evaluate the ability of the rapid Brain Attack Team (BAT) MRI in selecting patients for IV-tPA administration who present acutely to the emergency room with stroke-like symptoms and an unclear diagnosis. Methods Consecutive patients were identified who presented within 4.5 hours of onset of stroke-like symptoms and considered for treatment with IV-tPA. When the diagnosis was not clear, a 9-minute BAT MRI was obtained. Stroke risk factors and NIH stroke scale obtained on presentation were compared between patients in whom BAT MRI was obtained and those in whom BAT MRI was not obtained. Similarly, comparisons were made between patients in whom BAT MRI detected abnormalities and those in whom BAT MRI did not detect abnormalities. BAT MRIs were analyzed to determine if radiological findings impacted clinical management and discharge diagnosis. Results In a 30-month period, 432 patients presenting with acute stroke-like symptoms were identified. Of these patients, 82 received BAT MRI. Patients receiving BAT MRI were younger, more likely to be smokers, and less likely to be selected for IV-tPA administration compared to those in whom a more definitive diagnosis of stroke precluded a BAT MRI. Of the 82 BAT MRIs, 25 were read as positive for acute ischemia. The patients with acute ischemia on BAT MRI were older, more likely to be males, have a history of hypercholesterolemia and atrial fibrillation, and more likely to be selected for IV-tPA administration compared to those with a negative BAT MRI. Of the 57 BAT MRIs read as negative for acute ischemia or hemorrhage, discharge diagnoses included TIA, MRI negative stroke, conversion/functional disorder, and multiple other illnesses. Conclusion In patients with acute stroke-like symptoms, BAT MRI may be used to confirm acute ischemic stroke, exclude stroke mimics, and assess candidacy for IV-tPA.

Patient candidacy for acute stroke intervention, is currently assessed using brain computed tomography angiography (CTA) evidence of significant stenosis/occlusion (SSO) with a high National Institutes of Health Stroke Scale (NIHSS) (>6). This study examined the association between CTA without significant stenosis/occlusion (NSSO) and lower NIHSS (≤ 6) with transient ischemic attack (TIA) and other good clinical outcomes at discharge. Patients presenting <8 hours from stroke symptom onset, had an NIHSS assessment and brain CTA performed at presentation. Good clinical outcomes were defined as: discharge diagnosis of TIA, modified Rankin Score [mRS] ≤ 1, and home as the discharge disposition. Eighty-five patients received both an NIHSS at presentation and a CTA at 4.2 ± 2.2 hours from stroke symptom onset. Patients with NSSO on CTA as well as those with NIHSS≤6 had better outcomes at discharge (p<0.001). NIHSS ≤ 6 were more likely than NSSO (p=0.01) to have a discharge diagnosis of TIA (p<0.001). NSSO on CTA and NIHSS ≤ 6 also correlated with fewer deaths (p<0.001). Multivariable analyses showed NSSO on CTA (Adjusted OR: 5.8 95% CI: 1.2-27.0, p=0.03) independently predicted the discharge diagnosis of TIA. Addition of NIHSS ≤ 6 to NSSO on CTA proved to be a stronger independent predictor of TIA (Adjusted OR 18.7 95% CI: 3.5-98.9, p=0.001).

Background: South Carolina (SC) is located in the “buckle” of the stroke belt with one of the highest stroke death rates in the country. In 2010, SC had 66 acute care hospitals caring for strokes, nine of which were certified primary stroke centers (PSC). The rate of intravenous tissue plasminogen activator (IV-tPA) use and its correlates have not been investigated in the state. Objectives: To study the rate of IV-tPA use and its correlates using the statewide hospital discharge records stored at SC Department of Health and Environmental Control (DHEC), for the calendar year 2010. Methods: A retrospective analysis was conducted of the statewide hospital discharge records stored at SC DHEC, for the calendar year 2010. Patients with a discharge diagnosis of ischemic stroke were included in the analysis. Variables considered included patient demographics, insurance status, location/type of destination hospital, and treatment with IV-tPA. Results: In the calendar year 2010, 10,377 hospitalized patients in SC were assigned a primary discharge diagnosis of ischemic stroke. Of these, 4.2% (442) were treated with IV-tPA. Those who were treated with IV-tPA were younger (mean age ± standard deviation=66.7 ± 14.4, p=0.002) compared with those who did not receive IV-tPA (68.8±13.6). Patients treated at a PSC (49% of all ischemic stroke patients) were more likely to receive IV-tPA (Odds Ratio or OR 4.0, 95% CI 3.2-5.0).Patients treated in hospitals located in urban counties were more likely to receive IV-tPA compared to those treated in rural counties (OR 1.3, 95% CI 1.1-5.3). On multivariate logistic regression analysis, patients treated at a PSC (Adjusted OR 2.2, 95% CI 1.9-2.5) and those treated in urban counties (Adjusted OR 1.4, 95% CI 1.1-1.8) independently increased the likelihood of receiving IV-tPA. Gender, race and insurance status did not significantly change the likelihood of receiving IV-tPA. Conclusions: Younger stroke patients, treatment in a PSC and hospitals located in an urban county increased the likelihood of receiving IV-tPA. Increasing community awareness of PSCs, their location and designation may increase the rate of IV-tPA use.

Background: Intravenous Tissue Plasminogen Activator (TPA) is the only FDA approved medical therapy for acute ischemic stroke (AIS). Prior study suggests that early recanalization is associated with better stroke outcome. Our aim was to correlate task-negative and task-positive (TN/TP) resting state network activity with tissue perfusion and functional outcome, in stroke patients who received TPA. Method: AIS patients were consented and underwent NIH stroke scale (NIHSS) assessment and magnetic resonance imaging (MRI) scans during TPA infusion (baseline) and six hours post stroke. The MRI sequences include contrast-enhanced perfusion weighted image (PWI) and resting state Blood Oxygen Level-Dependent or BOLD (RSB) images acquired using a Siemens Treo 3T MRI scanner. Additionally, the RSB scan and the NIHSS were obtained at a 30-day follow up visit. Results: Fourteen patients (mean age ± SD=63 ±14, 50% male, 50% white, 43% black and 7% others) who qualified for TPA completed the study at baseline and 6 hours post stroke. Of these, 6 patients had valid follow up data at 30 days. Three patients without cerebral ischemia were excluded. A paired samples t-test comparing baseline and 6h post stroke showed a significantly improved TP network t(10)= -4.24 p< 0.05. The resting network connectivity improved from 6 hours post stroke to 30-days follow up, t(5)= -5.35 p< 0.01. Similarly, NIHSS, at 6h post stroke t(10)= 3.62 p< 0.01 and at 30-days follow up t(5)= -3.4 p< 0.01 were significantly better than the NIHSS at baseline. The 6-hours post-stroke perfusion correlated with the resting network connectivity in both the damaged (r=-0.56 p= 0.07) and intact hemispheres (r= -0.57 p= 0.06). Differences in functional connectivity and NIHSS scores from baseline to 6 h were positively correlated (r= 0.56 p=0.07). Conclusion: In this pilot study we found that TPA led to changes in MRI based resting state networks and associated functional outcome. Correlations were found between perfusion, functional connectivity and NIHSS. This suggests that the improvement of resting state network means improved efficiency of brain activity indicated by functional outcome and may be a potential predictive MRI biomarker for TPA response. A larger study is needed to verify this finding.