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Introduction: One in 3 strokes occur in patients with pre-stroke disability. This excludes many from acute treatment trials, but whether these patients benefit from aggressive treatment is unknown. Methods: A prospective stroke center registry (10/2019-04/2021) of consecutive adult patients with acute stroke was queried for patients with pre-stroke modified Rankin Scale (mRS) of 0-4. Multivariable logistic regression was used to estimate odds of full functional recovery (FFR) at 90 days (mRS 0-2 or return to pre-stroke mRS), comparing those with significant pre-stroke disability (mRS 3, 4) to those without (mRS 0-2). Results: Of 1228 patients, 1190 (97%) had pre-stroke mRS 0-4, with 856 (70%) included patients also having 90d follow-up mRS. The median age was 68y (IQR 59-78), with a median NIH Stroke Scale (NIHSS) of 5 (IQR 2-17). Compared to those with mRS 0-2 (n=722), patients with a pre-stroke mRS of 3 (n=96) or 4 (n=38) had more frequent comorbidities and were less likely to achieve FFR (Table). After multivariable adjustment, the odds of FFR was no less for patients with prestroke mRS of 3 (ORadj 1.37, 95%CI 0.80-2.34) or 4 (ORadj 0.59, 95%CI 0.25-1.39). In that model, FFR was less likely among the elderly (ORadj per year 0.96, 95%CI 0.95-0.97) and higher NIHSS (ORadj per point 0.89, 95%CI 0.88-0.91). Thrombolysis was strongly associated with FFR (ORadj 2.70, 95%CI 1.59-4.60). Conclusions: In this single center analysis, stroke recovery in the setting of pre-existing disability was driven by age and stroke severity. Thrombolysis remained predictive of FFR irrespective of age and stroke severity, but was underutilized in patients with pre-stroke disability.

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Introduction: Ipsilateral nonstenotic (<50%) internal carotid artery (ICA) plaque, cardiac atriopathy, and patent foramen ovale (PFO) may account for a substantial proportion of embolic stroke of undetermined source (ESUS). Methods: Consecutive stroke patients at our center (2019-2021) with unilateral, anterior ESUS were categorized into the following mutually exclusive etiologies: (1) nonstenotic ipsilateral ICA plaque (≥3mm), (2) atriopathy (sex-adjusted mod-to-severe atrial enlargement) & (3) PFO. Clinical and diagnostic results were compared between patients in each group, and against those with “true ESUS” (who failed to meet criteria for these 3 groups). Results: Of 133 included patients, there was minimal overlap between the mutually exclusive ESUS etiologies (2 having nonstenotic plaque + atriopathy, and 1 having atriopathy + PFO). Older patients more frequently had atriopathy, while patients with PFO had fewer vascular risk factors when compared to the other groups (padj≤0.1; Table). Patients with nonstenotic plaque had more frequent tobacco use (p=0.06), more severe white matter disease (p=0.07), and greater ipsilateral v. contralateral plaque (p<0.01). Twice as many patients with atriopathy presented with an ICA/M1/basilar occlusion (54%) when compared to other groups (p=0.03). Atriopathy was independently associated with older age (ORadj 1.09/year, 95%CI 1.02-1.17) and proximal occlusion (ORadj 16.47, 95%CI 2.86-94.65), with tobacco use associated with a non-atriopathic origin (ORadj 5.56/year, 95%CI 1.07-29.01). Five of 8 patients with atriopathy (63%) monitored with outpatient telemetry had atrial fibrillation, while 3/30 (10%) “true ESUS” and 0/12 (0%) nonstenotic plaque patients had atrial fibrillation. Conclusions: Certain clinical and radiographic features may be useful in predicting the proximal source of occult cerebral emboli, and can be used for cost-effective outpatient diagnostic testing.