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Perfusion deficits are found in TIA patients using whole brain CTP and associated with components of the ABCD2 score.

Background: Despite the efficacy of Direct Oral Anticoagulants (DOACs) in Nonvalvular Atrial Fibrillation (NVAF), some patients may still develop an ischemic stroke while taking this medication. This can be from a primary efficacy problem, called DOAC “True failure” (due to drug absorption, metabolism, or clearance), or DOAC “Pseudo-failure” (due to alternate causes of stroke, not the NVAF). We aim to study the factors contributing to DOAC Pseudo-failures and isolate DOAC True Failure rates. Methods: IRB-approved, retrospective study of NVAF patients on DOAC who developed ischemic stroke between Jan 2012 and Dec 2017. Variables reviewed include DOAC Pseudo-failure causes listed in the mnemonic CHAMP: C for Compliance concerns (adherence [held for procedure, ran out, or discontinued], incorrect dose, or incorrect frequency [QD vs BID]); H for Hypertensive lacunar disease; A for Arterial diseases (such as Atherosclerosis [intra- or extra-cranial, carotid or vertebral arterial stenosis or dissection]); M for Malignant cancer or other hypercoagulable states; and P for Patent Foramen Ovale (PFO). Results: We identified 87 NVAF patients on DOAC who presented with ischemic stroke: 18 on Dabigatran, 37 on Apixaban and 32 on Rivaroxaban. Of those, 67 patients (77%) had at least one of the CHAMP variables (DOAC Pseudo-failure) while 20 (23%) were DOAC True failures. Compliance concerns were responsible for nearly half (49%) of the Pseudo-failures, followed by Malignancy/hypercoagulability (26%), Arterial disease (17%), HTN (5.7%) and PFO (2.3%). True Failure was lowest for Dabigatran (5.6%) followed by Apixaban (16%) and highest with Rivoraxaban (41%) despite its high compliance rate of 66%. Compliance for the BID DOACs (Dabigatran and Apixaban) were similar at 39 % and 43%, respectively. Conclusion: Patients on DOAC for NVAF who develop ischemic stroke are three times more likely to have another identifiable etiology. Compliance concerns, Cancer/Hypercoagulability, and arterial disease represent over 90% of DOAC Pseudo-failures. Thus, providers should educate patients on correct DOAC doses and frequencies, and screen presumed DOAC failures with scans of the chest, abdomen and pelvis in addition to intracranial and extracranial vessel imaging.

Background: Most stroke patients have their stroke in the community setting, however a significant minority occur while hospitalized for another condition. Prior studies have noted worse outcomes for in-hospital strokes(IHS) compared to community-onset strokes(COS). IHS are also less likely to receive intravenous thrombolytic therapy. The increased use of mechanical thrombectomy(MT) and distinct eligibility criteria from thrombolysis provide additional therapy options for these patients. We present one of the first comparison of outcomes looking specifically at MT for IHS versus COS. Methods: We performed an IRB-approved, retrospective cross-sectional study on patients who underwent MT at our center for acute ischemic stroke between Jan 2012 and Nov 2017. Variables reviewed included patient demographics, vascular risk factors, symptom recognition time, treatment time, and disability as measured by the Modified Rankin Scale(mRS). Statistical analyses were performed using logistic regression to assess the relationship between IHS versus COS. Results: We studied 334 patients (290 COS and 44 IHS) who were treated with MT for acute ischemic stroke. Patients who presented in-hospital were younger (60.7 vs. 70.4 years; p<0.001). IHS were more likely to have a history of coronary artery disease (48% vs. 25%; p<0.003) and tobacco use (32% vs. 16%; p<0.032), conversely, they had a lower rate of atrial fibrillation (20% vs. 42% p<0.005). No significant difference was noted in history of diabetes, hypertension, and dyslipidemia. IHS treated with MT had lower use of intravenous thrombolysis (14% vs 34%; p<0.006). Patients with IHS had a significantly shorter mean symptom recognition to femoral stick time (p<0.039). In addition, IHS patients had significantly better outcomes at discharge as measured by mRS 0-3 (mRS range, 0-6; lower scores indicating less disability). After adjustment for age and stroke severity (National Institute of Health Stroke Scale) IHS continued to have better outcomes at discharge as measured by mRS 0-3; AOR=4.832; 95% Cl, (1.207-19.348); P< 0.026. Conclusion: In conclusion, time from symptom recognition to MT is faster for IHS vs. COS. In addition, IHS had less disability after mechanical thrombectomy for large vessel occlusion.