ObjectiveTo summarise evidence of the effects of blood pressure (BP)-lowering interventions after acute spontaneous intracerebral haemorrhage (ICH).MethodsA prespecified systematic review of the Cochrane Central Register of Controlled Trials, EMBASE and MEDLINE databases from inception to 23 June 2020 to identify randomised controlled trials that compared active BP-lowering agents versus placebo or intensive versus guideline BP-lowering targets for adults <7 days after ICH onset. The primary outcome was function (distribution of scores on the modified Rankin scale) 90 days after randomisation. Radiological outcomes were absolute (>6 mL) and proportional (>33%) haematoma growth at 24 hours. Meta-analysis used a one-stage approach, adjusted using generalised linear mixed models with prespecified covariables and trial as a random effect.ResultsOf 7094 studies identified, 50 trials involving 11 494 patients were eligible and 16 (32.0%) shared patient-level data from 6221 (54.1%) patients (mean age 64.2 [SD 12.9], 2266 [36.4%] females) with a median time from symptom onset to randomisation of 3.8 hours (IQR 2.6–5.3). Active/intensive BP-lowering interventions had no effect on the primary outcome compared with placebo/guideline treatment (adjusted OR for unfavourable shift in modified Rankin scale scores: 0.97, 95% CI 0.88 to 1.06; p=0.50), but there was significant heterogeneity by strategy (pinteraction=0.031) and agent (pinteraction<0.0001). Active/intensive BP-lowering interventions clearly reduced absolute (>6 ml, adjusted OR 0.75, 95%CI 0.60 to 0.92; p=0.0077) and relative (≥33%, adjusted OR 0.82, 95%CI 0.68 to 0.99; p=0.034) haematoma growth.InterpretationOverall, a broad range of interventions to lower BP within 7 days of ICH onset had no overall benefit on functional recovery, despite reducing bleeding. The treatment effect appeared to vary according to strategy and agent.PROSPERO registration numberCRD42019141136.

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ObjectiveTo assess the impact of interhospital transfer on the interplay between functional outcome, mortality, reperfusion rates and workflow time metrics in patients undergoing endovascular thrombectomy (EVT) for acute ischaemic stroke due to large vessel occlusion (LVO) in the anterior cerebral circulation.Design, setting and participantsThis is an analysis of a prospective database of consecutive patients undergoing EVT for LVO presenting between January 2017 and December 2018 at a single Australian comprehensive stroke centre (CSC). Patients presented directly or were transferred to the CSC from 21 sites across New South Wales and the Australian Capital Territory.Main outcome measuresThe main outcome measures were rate of good 90-day functional outcome (modified Rankin Scale 0–2), successful reperfusion (Thrombolysis in Cerebral Infarction scale grade 2b or 3), symptomatic intracerebral haemorrhage (sICH) and 90-day mortality. Key workflow time metric milestones were examined.Results154 of 213 (72%) patients were interhospital transfers. There was no significant difference in baseline characteristics including age, National Institutes of Health Stroke Scale score, intravenous thrombolysis administration or procedure time between transferred and direct presenters (all p>0.05). Transferred patients had worse 90-day functional outcome (39.6% vs 61.0%, OR 0.42, 95% CI 0.23 to 0.78), higher mortality (25.3% vs 6.8%, OR 4.66, CI 1.59 to 13.70) and longer stroke onset to treatment (groin puncture) time (298 min vs 205 min, p<0.01). Successful reperfusion rates and sICH were similar between the cohorts (96.8% vs 98.3%, and 7.8% vs 3.4%).ConclusionInterhospital transfer is associated with longer stroke onset to treatment, worse 90-day functional outcome and higher mortality compared with patients presenting directly to the CSC.

Aim: Patients with atrial fibrillation (AF) are over-represented in endovascular thrombectomy (EVT) populations, due to a high prevalence of large vessel occlusions (LVO) and contraindication to intravenous thrombolysis. This study aimed to: (1) compare 90-day functional outcomes [modified Rankin Score (mRS) 0-2] and mortality in AF vs. non-AF patients receiving EVT; (2) compare 90-day functional outcomes and mortality in AF patients on therapeutic vs. non-therapeutic anticoagulation receiving EVT; and (3) identify factors influencing outcomes in AF patients receiving EVT.Methods: A retrospective analysis of 394 consecutive patients who received EVT for anterior cerebral circulation LVO at an Australian comprehensive stroke center was performed. The main outcome measures [90-day dichotomized mRS (0-2 good; 3-6 poor functional outcome) and mortality] were compared between AF and non-AF patients, as well as between therapeutic and non-therapeutic anticoagulation cohorts.Results: In total, 171 (49%) EVT patients had AF. Patients with AF were older, had higher NIHSS, and had lower rates of thrombolysis administration. AF patients showed improved 90-day mRS on multivariate analysis [aOR 1.988 (1.167-3.387)], with similar symptomatic intracranial hemorrhage (sICH) [aOR 0.364 (0.064-2.086)] and mortality ]. There was no difference in 90-day mRS ], successful reperfusion rates )], or mortality [aOR 1.077 (0.429-2.705)] between AF patients on therapeutic vs. non-therapeutic anticoagulation. In patients with AF, advancing age and higher NIHSS were independent predictors of worse 90-day functional outcome (OR = 1.045, P = 0.020; OR = 1.086, P = 0.001) and mortality (OR = 1.138, P < 0.001; OR = 1.107, P = 0.002). On multivariate analysis, thrombolysis administration improved mortality (OR = 0.215, P = 0.016) but not functional outcomes. Conclusion:Patients with AF showed improved 90-day functional outcome, with similar mortality and sICH, after EVT. Therapeutic anticoagulation did not adversely influence EVT outcomes.

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<b><i>Introduction:</i></b> In a multicentre study, we contrasted cerebrovascular disease profiles in Pacific Island (PI)-born patients (Indigenous Polynesian [IP] or Indo-Fijian [IF]) presenting with transient ischaemic attack (TIA), ischaemic stroke (IS) or intracerebral haemorrhage (ICH) with those of Caucasians (CSs). <b><i>Methods:</i></b> Using a retrospective case-control design, we compared PI-born patients with age- and gender-matched CS controls. Consecutive patients were admitted to 3 centres in South Western Sydney (July 2013–June 2020). Demographic and clinical data studied included vascular risk factors, stroke subtypes, and imaging characteristics. <b><i>Results:</i></b> There were 340 CS, 183 (27%) IP, and 157 (23%) IF patients; mean age 65 years; and 302 (44.4%) female. Of these, 587 and patients presented with TIA/IS and 93 (13.6%) had ICH. Both IP and IF patients were significantly more likely to present &#x3e;24 h from symptom onset (odds ratios [ORs] vs. CS 1.87 and 2.23). IP patients more commonly had body mass indexes &#x3e;30 (OR 1.94). Current smoking and excess alcohol intake were higher in CS. Hypertension, diabetes, and chronic kidney disease were significantly higher in both IP and IF groups in comparison to CS. IP patients had higher rates of AF and those with known AF were more commonly undertreated than both IF and CS patients (OR 2.24, <i>p</i> = 0.007). ICH was more common in IP patients (OR 2.32, <i>p</i> = 0.005), while more IF patients had intracranial arterial disease (OR 5.10, <i>p</i> &#x3c; 0.001). <b><i>Discussion/Conclusion:</i></b> Distinct cerebrovascular disease profiles are identifiable in PI-born patients who present with TIA or stroke symptoms in Australia. These may be used in the future to direct targeted approaches to stroke prevention and care in culturally and linguistically diverse populations.

<b><i>Background and Purpose:</i></b> The benefit of bridging intravenous thrombolysis (IVT) in acute ischaemic stroke patients eligible for endovascular thrombectomy (EVT) is unclear. This may be particularly relevant where reperfusion is achieved with multiple thrombectomy passes. We aimed to determine the benefit of bridging IVT in first and multiple-pass patients undergoing EVT ≤6 h from stroke onset to groin puncture. <b><i>Methods:</i></b> We compared 90-day modified Rankin Scale (mRS) outcomes in 187 consecutive patients with large vessel occlusions (LVOs) of the anterior cerebral circulation who underwent EVT ≤6 h from symptom onset and who achieved modified thrombolysis in cerebral ischaemia (mTICI) 2c/3 reperfusion with the first pass to those patients who required multiple passes to achieve reperfusion. The effect of bridging IVT on outcomes was examined. <b><i>Results:</i></b> Significantly more first-pass patients had favourable (mRS 0–2) 90-day outcomes (68 vs. 42%, <i>p</i> = 0.001). Multivariate analysis showed an association between first-pass reperfusion and favourable outcomes (OR 2.25; 95% CI 1.08–4.68; <i>p</i> = 0.03). IVT provided no additional benefit in first-pass patients (OR 1.17; CI 0.42–3.20; <i>p</i> = 0.76); however, in multiple-pass patients, it reduced the risk of disabling stroke (mRS ≥4) (OR 0.30; CI 0.10–0.88; <i>p</i> = 0.02) and mortality (OR 0.07; CI 0.01–0.36; <i>p</i> = 0.002) at 90 days. <b><i>Conclusion:</i></b> Bridging IVT may benefit patients with anterior circulation stroke with LVO who qualify for EVT and who require multiple passes to achieve reperfusion.

Background: Definitive diagnosis of acute ischemic stroke is challenging, particularly in telestroke settings. Although the prognostic utility of CT perfusion (CTP) has been questioned, its diagnostic value remains under-appreciated, especially in cases without an easily visible intracranial occlusion. We assessed the diagnostic accuracy of routine CTP in the acute telestroke setting. Methods: Acute and follow-up data collected prospectively from consecutive suspected patients with stroke assessed by a state-wide telestroke service between March 2020 and August 2021 at 12 sites in Australia were analyzed. All patients in the final analysis had been assessed with multimodal CT, including CTP, which was post-processed with automated volumetric software. Diagnostic sensitivity and specificity were calculated for multimodal CT and each individual component (noncontrast CT [NCCT], CT angiogram [CTA], and CTP). Final diagnosis determined by consensus review of follow-up imaging and clinical data was used as the reference standard. Results: During the study period, complete multimodal CT examination was obtained in 831 patients, 457 of whom were diagnosed with stroke. Diagnostic sensitivity for ischemic stroke increased by 19.5 percentage points when CTP was included with NCCT and CTA compared with NCCT and CTA alone (73.1% positive with NCCT+CTA+CTP [95% CI, 68.8–77.1] versus 53.6% positive with NCCT+CTA alone [95% CI, 48.9–58.3], P <0.001). No difference was observed between specificities of NCCT+CTA and NCCT+CTA+CTP (98.7% [95% CI, 98.5–100] versus 98.7% [95% CI, 96.9–99.6], P =0.13). Multimodal CT, including CTP, demonstrated the highest negative predictive value (75.0% [95% CI, 72.1–77.7]). Patients with stroke not evident on CTP had small volume infarcts on follow-up (1.2 mL, interquartile range 0.5–2.7mL). Conclusions: Acquisition of CTP as part of a telestroke imaging protocol permits definitive diagnosis of cerebral ischemia in 1 in 5 patients with normal NCCT and CTA.