ObjectiveTo update the 2016 American Academy of Neurology (AAN) practice advisory for patients with stroke and patent foramen ovale (PFO).MethodsThe guideline panel followed the AAN 2017 guideline development process to systematically review studies published through December 2017 and formulate recommendations.Major recommendationsIn patients being considered for PFO closure, clinicians should ensure that an appropriately thorough evaluation has been performed to rule out alternative mechanisms of stroke (level B). In patients with a higher risk alternative mechanism of stroke identified, clinicians should not routinely recommend PFO closure (level B). Clinicians should counsel patients that having a PFO is common; that it occurs in about 1 in 4 adults in the general population; that it is difficult to determine with certainty whether their PFO caused their stroke; and that PFO closure probably reduces recurrent stroke risk in select patients (level B). In patients younger than 60 years with a PFO and embolic-appearing infarct and no other mechanism of stroke identified, clinicians may recommend closure following a discussion of potential benefits (absolute recurrent stroke risk reduction of 3.4% at 5 years) and risks (periprocedural complication rate of 3.9% and increased absolute rate of non-periprocedural atrial fibrillation of 0.33% per year) (level C). In patients who opt to receive medical therapy alone without PFO closure, clinicians may recommend an antiplatelet medication such as aspirin or anticoagulation (level C).

Objective: To update the 2004 American Academy of Neurology guideline for patients with stroke and patent foramen ovale (PFO) by addressing whether (1) percutaneous closure of PFO is superior to medical therapy alone and (2) anticoagulation is superior to antiplatelet therapy for the prevention of recurrent stroke.Methods: Systematic review of the literature and structured formulation of recommendations.Conclusions: Percutaneous PFO closure with the STARFlex device possibly does not provide a benefit in preventing stroke vs medical therapy alone (risk difference [RD] 0.13%, 95% confidence interval [CI] 22.2% to 2.0%). Percutaneous PFO closure with the AMPLATZER PFO Occluder possibly decreases the risk of recurrent stroke (RD 21.68%, 95% CI 23.18% to 20.19%), possibly increases the risk of new-onset atrial fibrillation (AF) (RD 1.64%, 95% CI 0.07%-3.2%), and is highly likely to be associated with a procedural complication risk of 3.4% (95% CI 2.3%-5%). There is insufficient evidence to determine the efficacy of anticoagulation compared with antiplatelet therapy in preventing recurrent stroke (RD 2%, 95% CI 221% to 25%).Recommendations: Clinicians should not routinely offer percutaneous PFO closure to patients with cryptogenic ischemic stroke outside of a research setting (Level R). In rare circumstances, such as recurrent strokes despite adequate medical therapy with no other mechanism identified, clinicians may offer the AMPLATZER PFO Occluder if it is available (Level C). In the absence of another indication for anticoagulation, clinicians may routinely offer antiplatelet medications instead of anticoagulation to patients with cryptogenic stroke and PFO (Level C).

ImportanceIn patients with severe aortic valve stenosis at intermediate surgical risk, transcatheter aortic valve replacement (TAVR) with a self-expanding supra-annular valve was noninferior to surgery for all-cause mortality or disabling stroke at 2 years. Comparisons of longer-term clinical and hemodynamic outcomes in these patients are limited.ObjectiveTo report prespecified secondary 5-year outcomes from the Symptomatic Aortic Stenosis in Intermediate Risk Subjects Who Need Aortic Valve Replacement (SURTAVI) randomized clinical trial.Design, Setting, and ParticipantsSURTAVI is a prospective randomized, unblinded clinical trial. Randomization was stratified by investigational site and need for revascularization determined by the local heart teams. Patients with severe aortic valve stenosis deemed to be at intermediate risk of 30-day surgical mortality were enrolled at 87 centers from June 19, 2012, to June 30, 2016, in Europe and North America. Analysis took place between August and October 2021.InterventionPatients were randomized to TAVR with a self-expanding, supra-annular transcatheter or a surgical bioprosthesis.Main Outcomes and MeasuresThe prespecified secondary end points of death or disabling stroke and other adverse events and hemodynamic findings at 5 years. An independent clinical event committee adjudicated all serious adverse events and an independent echocardiographic core laboratory evaluated all echocardiograms at 5 years.ResultsA total of 1660 individuals underwent an attempted TAVR (n = 864) or surgical (n = 796) procedure. The mean (SD) age was 79.8 (6.2) years, 724 (43.6%) were female, and the mean (SD) Society of Thoracic Surgery Predicted Risk of Mortality score was 4.5% (1.6%). At 5 years, the rates of death or disabling stroke were similar (TAVR, 31.3% vs surgery, 30.8%; hazard ratio, 1.02 [95% CI, 0.85-1.22]; P = .85). Transprosthetic gradients remained lower (mean [SD], 8.6 [5.5] mm Hg vs 11.2 [6.0] mm Hg; P < .001) and aortic valve areas were higher (mean [SD], 2.2 [0.7] cm2 vs 1.8 [0.6] cm2; P < .001) with TAVR vs surgery. More patients had moderate/severe paravalvular leak with TAVR than surgery (11 [3.0%] vs 2 [0.7%]; risk difference, 2.37% [95% CI, 0.17%- 4.85%]; P = .05). New pacemaker implantation rates were higher for TAVR than surgery at 5 years (289 [39.1%] vs 94 [15.1%]; hazard ratio, 3.30 [95% CI, 2.61-4.17]; log-rank P < .001), as were valve reintervention rates (27 [3.5%] vs 11 [1.9%]; hazard ratio, 2.21 [95% CI, 1.10-4.45]; log-rank P = .02), although between 2 and 5 years only 6 patients who underwent TAVR and 7 who underwent surgery required a reintervention.Conclusions and RelevanceAmong intermediate-risk patients with symptomatic severe aortic stenosis, major clinical outcomes at 5 years were similar for TAVR and surgery. TAVR was associated with superior hemodynamic valve performance but also with more paravalvular leak and valve reinterventions.

Paragonimus kellicotti is an emerging pathogen in the United States with 19 previously reported cases, most in Missouri. Pulmonary symptoms with eosinophilia are most common, though 1 case did involve the central nervous system with few symptoms. We describe the first 2 cases of eosinophilic meningitis due to Paragonimus kellicotti.

Purpose For individuals with acute stroke, it is difficult to conduct an exercise test to assess peak oxygen consumption (peak Vo2). Therefore, the purpose of this study was to use a clinically feasible tool for assessing prestroke peak Vo2 using a nonexercise estimation equation to test whether estimated prestroke peak Vo2 was related to the functional outcome measures at discharge from the hospital in individuals after an acute stroke. We hypothesized that the estimated prestroke peak Vo2 would be significantly related to discharge Physical Performance Test (PPT), 6-minute walk test (6MWT), and lower extremity Fugl-Meyer (LEFM) assessment. Methods Estimated prestroke peak Vo2 was calculated using a previously validated prediction equation using the following variables: body mass index, age, sex, resting heart rate, and a self-reported measure of physical activity. Outcome measures were assessed 4 days after enrollment or immediately before discharge (whichever occurred first). Results Thirty-four participants (mean age = 56.0, SD = 12.6 years; 20 men) with acute stroke were enrolled within 48 hours of admission. For all individuals, mean estimated prestroke peak Vo2 was 27.3 (SD = 7.4) mL·kg−1·min−1 and had a weak, nonsignificant relationship with the PPT (r = 0.19; P = .28), 6MWT (r = 0.10; P = .56), and LEFM (r = 0.32; P = .06). However, when considering sex, women, but not men, had a significant relationship with LEFM (r = 0.73; P = .005) and moderate but nonsignificant relationship with PPT (r = 0.53; P = .06) and 6MWT (r = 0.47; P = .10). Conclusions Within 48 hours of stroke admission, we were able to administer a nonexercise equation to estimate prestroke peak Vo2. For the entire sample, functional measures conducted at discharge were not related to estimated prestroke peak Vo2. However, when considering sex, the relationship between prestroke Vo2 and the functional measures was strengthened.

Background and Objectives:The effect of anesthesia choice on endovascular thrombectomy(EVT) outcomes is unclear. Collateral status on perfusion imaging may help identify the optimal anesthesia choice.Methods:In a pooled patient level analysis of EXTEND-IA, EXTEND-IA TNK, EXTEND-IA TNK part II and SELECT, EVT functional outcomes(mRS distribution) were compared between general anesthesia(GA) vs non-general anesthesia(non-GA) in a propensity matched sample. Further, we evaluated the association of collateral flow on perfusion imaging, assessed by hypoperfusion intensity ratio(HIR) – Tmax>10s/Tmax>6s(good collaterals – HIR<0.4, poor collaterals – HIR≥0.4) on the association between anesthesia type and EVT outcomes.Results:Of 725 treated with EVT, 299(41%) received GA and 426(59%) non-GA. The baseline characteristics differed in presentation NIHSS(median[IQR]-GA:18[13-22], non-GA:16[11-20],p<0.001) and ischemic core volume(GA:15.0mL[3.2-38.0] vs non-GA:9.0mL[0.0-31.0],p<0.001). Additionally, GA was associated with longer last-known-well(LKW) to arterial access (203min[157-267] vs 186min[138-252],p=0.002), but similar procedural time (35.5min[23-59] vs 34min[22-54],p=0.51). Of 182 matched pairs using propensity scores, baseline characteristics were similar. In the PS-matched pairs, GA was independently associated with worse functional outcomes(adj cOR:0.64,95%CI:0.44-0.93,p=0.021) and higher neurological worsening(GA:14.9% vs non-GA:8.9%, aOR:2.10,95%CI: 1.02-4.33,p=0.045). Patients with poor collaterals had worse functional outcomes with GA(adj cOR:0.47,95%CI:0.29-0.76,p=0.002), while no difference was observed in those with good collaterals(adj. cOR:0.93,95%CI:0.50-1.74,p=0.82), Pinteraction:0.07. No difference was observed in infarct growth overall and in patients with good collaterals, whereas patients with poor collaterals demonstrated larger infarct growth with GA with a significant interaction between collaterals and anesthesia type on infarct growth rate(Pinteraction:0.020).Conclusion:GA was associated with worse functional outcomes after EVT, particularly in patients with poor collaterals in a PS matched analysis from a pooled, patient-level cohort from 3 randomized trials and one prospective cohort study. The confounding by indication may persist despite the doubly robust nature of the analysis. These findings have implications for randomized trials of GA vs non-GA and may be of utility for clinicians when making anesthesia type choice.Classification of Evidence:This study provides Class III evidence that that use of general anesthesia is associated with worse functional outcome in patients undergoing endovascular thrombectomy.Trial registrations:EXTEND-IA:ClinicalTrials.gov (NCT01492725); EXTEND-IA TNK:ClinicalTrials.gov (NCT02388061); EXTEND-IA TNK part II:ClinicalTrials.gov (NCT03340493); SELECT:ClinicalTrials.gov (NCT02446587).

Comprehensive Stroke Centers (CSCs) provide leadership to the surrounding communities they serve. Until state certification is mandated through legislative action, CSCs may be the best actors to create and improve stroke systems of care. Our CSC is in a state with 83 out of 126 Critical Access Hospitals. We launched the Kansas Initiative for Stroke Survival (KISS) in 2012, offering training and resources on quality measures and protocols necessary to recognize and treat stroke. Hospitals were invited to do an assessment of what they needed to do to become “stroke ready” and sign an attestation that acute therapy could be administered with telephonic assistance from a tertiary center and a transfer plan in place. In the first two years, over sixty hospitals participated, but those enrolled in KISS as emergent stroke ready did not show sustained improvement in stroke care. Door to needle time increased 25% in the last year. In response, our CSC created an independent executive board, representing professionals from nursing, emergency medical services, management, and medicine, to lead a broader statewide approach to education and accountability. Our new goals are to develop a statewide capability map, distribute a quarterly newsletter highlighting efforts across the state, and develop a website with links to presentations, protocols, and statewide data. We have already redesigned the data survey to enhance reporting and analysis, community-level boot camps have been implemented, and a statewide peer review has begun. Our CSC leads the quarterly peer review along with education that covers topics impacting outcomes, such as time from door to thrombolytic therapy and endovascular case selection; the first conference had 27 participants across the state. Our experience demonstrates that CSCs can lead statewide improvements in stroke care and that hospitals around the state are receptive to that leadership. Collaboration between hospitals can improve stroke outcomes.

Background: The effect of anesthesia choice on endovascular thrombectomy (EVT) outcomes is unclear. Collateral status on perfusion imaging may help identify the optimal anesthesia choice. Methods: In a pooled patient level analysis of EXTEND-IA, EXTEND-IA TNK, EXTEND-IA TNK part II and SELECT, EVT Functional outcomes (mRS distribution) were compared between general anesthesia (GA) vs non-general anesthesia (non-GA). Further, we assessed the impact of collateral flow on perfusion imaging evaluated by hypoperfusion intensity ratio (HIR) - Tmax10 sec/Tmax6 sec) on the association between anesthesia type and EVT outcomes. Results: Of 731 treated with EVT, 305 (42%) received GA and 426 (58%) non-GA. The baseline characteristics were similar, except for presentation NIHSS (median [IQR] GA 18 [13-22], non-GA 16[11-20], p<0.001) and ischemic core volume (GA 14.1mL [3-37] vs non-GA 9mL [0-31], p=0.002). GA was associated with longer LKW to arterial access (203min [158-267] vs 186min [138-252], p=0.002), but similar procedural time (36min [23-59] vs 34min [22-54], p=0.36). Non-GA was independently associated with improved functional outcomes (adj cOR 1.42, 95%CI 1.05-1.93, p=0.024) and lower mortality (17% vs 11.3%, p=0.025). Patients with poor collaterals (HIR≥0.4) had improved functional outcomes with non-GA (adj cOR 1.53, 95%CI 1.02-2.29, p=0.038), while no difference was observed in those with good collaterals-HIR<0.4 (adj cOR 1.38, 95% CI 0.84-2.27, p=0.21). Conclusion: GA was associated with worse functional outcomes after EVT, particularly in patients with poor collaterals. These findings have implications for randomized trials of GA vs non-GA.