Objective: To determine whether exposure to traumatic brain injury (TBI) is associated with increased risk of stroke in adults compared with referents not exposed to TBI, and to understand whether an association exists throughout the spectrum of injury severity, whether it differs between the acute and chronic phases after TBI, and whether the association is greater with hemorrhagic compared with ischemic stroke after TBI. Setting: A database search was conducted on January 22, 2021. Searches were run in MEDLINE (1946 to present), Embase (1988 to present), Evidence-Based Medicine Reviews (various dates), Scopus (1970 to present), and Web of Science (1975 to present). Design: Observational studies that quantified the association of stroke after TBI compared with referents without TBI were included. Three coauthors independently reviewed titles and abstracts to determine study eligibility. Study characteristics were extracted independently by 2 coauthors who followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and study quality was assessed independently by 2 coauthors who used the Newcastle-Ottawa Scale. Random-effects meta-analyses were performed. Main Measures: The primary exposure was TBI of any severity, and the primary outcome was stroke of any kind. Subgroup analysis was performed to assess heterogeneity associated with severity of TBI, type of stroke, and time from TBI to stroke. Results: A total of 64 fulltext articles were reviewed, and data were extracted from 8 cohort studies (N = 619 992 individuals exposed to TBI along with nonexposed referents). A significant overall association was found with TBI and stroke (hazard ratio, 2.06; 95% CI, 1.28-3.32). Significant subgroup differences were found with a smaller risk of ischemic stroke compared with stroke of all types (P < .001, I 2 = 93.9%). Conclusions: TBI, regardless of injury severity, was associated with a higher risk of stroke. To improve secondary stroke prevention strategies, future studies should classify TBI severity and type of stroke more precisely and determine long-term risk.

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The administration of intravenous (IV) alteplase to patients with stroke via telestroke (TS) can be safe and effective. It remains unclear how quickly IV alteplase occurs during TS evaluations. We sought to compare door to needle times (DNTs) between patients receiving IV alteplase who present directly to our comprehensive stroke center (CSC) and those presenting to community hospitals in our TS network. Consecutive patients with acute ischemic stroke (AIS) who presented to emergency departments and received IV alteplase between August 2014 and June 2015 were identified at our CSC and TS network. Median DNTs with interquartile ranges were calculated in each cohort. During the study period, 117 patients with AIS (mean age 71 ± 15 years, 47% women) receiving IV alteplase were included in the analysis (65 CSC and 52 TS). Median DNT at our CSC was significantly shorter compared to TS sites (CSC: 43 [35-55] minutes vs TS: 54 [41-71] minutes, < .01). The proportion of patients receiving IV alteplase ≤60 minutes of presentation was significantly higher at our CSC compared to our TS network (CSC 84.6% vs TS 63.5%, = .02). Differences in favorable discharge to home were not significant (CSC 60% vs TS 46%, = .14). Guideline-recommended DNTs ≤60 minutes can be achieved in community hospitals with TS guidance. Initiatives are required to better resemble DNTs found at stroke centers.

Objective To reliably inform secondary prevention strategies and reduce morbidity and mortality after traumatic brain injury (TBI), we sought to understand the long-term risk of stroke after TBI in patients aged 40 years and older in comparison to age- and sex-matched referents from a population-based cohort. Materials and Methods TBI cases in Olmsted County, Minnesota from January 1, 1985 to December 31, 1999 were confirmed by manual review, classified by injury severity and mechanism, and non-head trauma was quantified. Each TBI case was matched to 2 sex- and age-matched population-based referents without TBI and with similar severity non-head trauma. Records of cases and referents were manually abstracted to confirm stroke diagnosis. Stroke events during initial hospitalization for TBI were excluded. Results In total, 1,410 TBI cases were confirmed, 61% classified as Possible TBI (least severe, consistent with concussive), with the most common mechanism being falls. There were 162 stroke events among those with TBI (11.5%), and 269 among referents (9.5%). Median time to stroke from the index date for those with TBI was 10.2 years (Q1-Q3 5.2 – 17.8), and for referents 12.1 years (Q1-Q3 6.2-17.3), P = 0.215. All-severity TBI was associated with increased risk of stroke (HR: 1.32, 95% CI: 1.06–1.63, P = 0.011), but only Definite TBI (consistent with moderate-severe) was associated with significant risk (HR: 2.20, 95% CI: 1.04-4.64, P = 0.038) when stratified by severity. Discussion/Conclusion By confirming TBI cases, stroke diagnoses, and injury severity classification using manual review with levels of accuracy not previously reported, these results indicate moderate-severe TBI increases long-term risk for stroke. These findings confirm the need to regularly assess long-term vascular risk after TBI to implement disease prevention strategies.

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Background: It has been established that safety and outcomes of intravenous thrombolysis (IVT) to stroke patients via telestroke (TS) is similar to those presenting to stroke centers. Little is known on the accuracy of TS diagnosis among those receiving IVT. We sought to compare the rate of stroke mimic (SM) patients receiving IVT in our TS network to those who present to our comprehensive stroke center (CSC). Methods: Consecutive patients receiving IVT between August 2014 and June 2015 were identified at our CSC and TS network. The rates of SM patients in each cohort were calculated. Outcomes measured included rates of symptomatic intracerebral hemorrhage (sICH), in-hospital mortality, and discharge to home or an acute rehabilitation unit (ARU). Results: During the study period, 132 patients (mean age 71±15 years, 49% women) receiving IVT were included in the analysis (75 CSC, 57 TS). Rates of SM patients receiving IVT were similar (CSC 12% vs TS 7%, p=0.39). One stroke patient developed sICH, and three other stroke patients experienced in-hospital mortality; neither outcome was found in the SM cohort. Discharge to home or ARU was similar between stroke (76.5%) and SM (76.9%) patients (p=1). Patients with SMs had significantly higher diagnoses of migraine (p=0.045) and psychiatric disorders (p=0.0002) compared to stroke patients. Conclusion: The rate of IVT among SM patients via TS is low and similar to those who present directly to a stroke center. Continued efforts should be made to further minimize IVT in SM patients despite the low rate of complications.

Background: The administration of intravenous thrombolysis (IVT) to stroke patients via telestroke (TS) can be safe and effective. It remains unclear how quickly IVT occurs during TS evaluations. We sought to compare door to needle times (DNT) between patients receiving IVT who present directly to our comprehensive stroke center (CSC) and those presenting to community hospitals in our TS network. Methods: Consecutive acute ischemic stroke (AIS) patients who presented to emergency departments and received IVT between August 2014 and June 2015 were identified at our CSC and TS network. Median DNTs with interquartile ranges (IQR) were calculated in each cohort. Outcomes measured included rates of symptomatic intracerebral hemorrhage, in-hospital mortality, and discharge to home or an acute rehabilitation unit (ARU). Results: During the study period, 117 AIS patients (mean age 71±15 years, 47% women) receiving IVT were included in the analysis (65 CSC, 52 TS). Median DNT at our CSC was significantly shorter compared to TS DNT (CSC 43 [IQR 35,55] minutes vs TS 54 [IQR 41,71.25] minutes, p=0.005). The proportion of patients receiving IVT within 60 minutes of presentation was significantly higher at our CSC compared to our TS network (CSC 84.6% vs TS 63.5%, p=0.01). Favorable discharge to home or ARU was similar (CSC 76.9% vs TS 75%, p=0.83). Conclusion: Guideline-recommended DNTs ≤60 minutes can be achieved in community hospitals with TS guidance. Initiatives are required to better resemble DNTs found at stroke centers.