BACKGROUND: Disparities in time to hospital presentation and prehospital stroke care may be important drivers in inequities in acute stroke treatment rates, functional outcomes, and mortality. It is unknown how patient-level factors, such as race and ethnicity and county-level socioeconomic status, affect these aspects of prehospital stroke care. METHODS: Cross-sectional study of patients with ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage in the Get With the Guidelines-Stroke registry, presenting from July 2015 to December 2019, with symptom onset ≤24 hours. Multivariable logistic regression and quantile regression were used to investigate the outcomes of interest: emergency medical services (EMS) transport (versus private vehicle), EMS prehospital notification (versus no prehospital notification), and stroke symptom onset to time of arrival at the emergency department. Prespecified covariates included patient-level, hospital-level, and county-level characteristics. RESULTS: The inclusion criteria was met by the 606 369 patients. Of the patients, 51.2% were men and 69.9% White, with a median National Institutes of Health Stroke Severity of 4 (IQR, 2–10), and median social deprivation index (SDI) of 51 (IQR, 27–75). Median symptom onset to arrival time was 176 minutes (IQR, 64–565). Black race was significantly associated with prolonged symptom onset to emergency department arrival time (+28.21 minutes [95% CI, 25.59–30.84]), and decreased odds of EMS prehospital notification (OR, 0.80 [95% CI, 0.78–0.82]). SDI was not associated with differences in EMS use but was associated with lower odds of EMS prehospital notification (upper SDI tercile versus lowest, OR, 0.79 [95% CI, 0.78–0.81]). SDI was also significantly associated with stroke symptom onset to emergency department arrival time (upper SDI tercile versus lowest +2.56 minutes [95% CI, 0.58–4.53]). CONCLUSIONS: In this national cross-sectional study, Black race was associated with prolonged symptom onset to time of arrival intervals and significantly decreased odds of EMS prehospital notification, despite similar use of EMS transport. Greater county-level deprivation was also associated with reduced odds of EMS prehospital notification and slightly prolonged stroke symptom onset to emergency department arrival time. Efforts to reduce place-based disparities in stroke care must address significant inequities in prehospital care of acute stroke and continue to address health inequities associated with race and ethnicity.

Objectives: We sought to determine the relative contributions of stroke, dementia, and their combination to disability and racial differences in disability among community-dwelling older adults. Methods: We performed a cross-sectional study of 6848 community-dwelling older adults. We evaluated the associations of stroke, dementia, and their combination with activities of daily living (ADL) limitations (range 0-7). We then explored the impact of stroke and dementia on race differences in ADL limitations using Poisson regression after accounting for sociodemographics and comorbidities. Results: After full adjustment, ADL limitations differed among older adults with stroke and dementia. Older adults without stroke or dementia had 0.32 (95% CI 0.29-0.35) ADL limitations compared to 0.64 (95% CI 0.54-0.73) with stroke, 1.36 (95% CI 1.20-1.53) with dementia and 1.84 (95% CI 1.54-2.15) with stroke and dementia. Overall, blacks had 0.27 (95%CI 0.19-0.36) more ADL limitations than whites. Models accounting for stroke led to a 3.7% (95%CI 2.98%-4.43%) reduction in race differences, while those for dementia led to a 29.26% (95%CI 28.53%-29.99%) reduction and the stroke-dementia combination −1.48% (95%CI −2.21% to −0.76) had little impact. Discussion: Older adults with stroke and dementia have greater disability than older adults with either of these conditions alone. However, the amount of disability experienced by older adults with stroke and dementia is less than the sum of the contributions from stroke and dementia. Dementia is likely a key contributor to race differences in disability.

Strokes involving the artery of Percheron (AOP), an anatomic variant of thalamic vascular supply, are rare. Little is known about the inpatient hospital course for these patients. We retrospectively identified consecutive patients with AOP in their medical charts from a university-based tertiary care hospital from January 1, 2000, to August 15, 2017. A chart review identified demographics, transfer status, in-hospital versus community onset of stroke, emergency medical services (EMS) use, presenting signs/symptoms, time to radiologic diagnosis (from time of presentation to tertiary care hospital or from time of initial symptom onset in an already hospitalized patient), tissue plasminogen activator (tPA) use, intensive care unit (ICU) stays, intubation, length of stay (LOS), and discharge location. After radiologic inclusion/exclusion criteria were applied, 12 patients were included in the study. There were 7 men and 5 women, and the mean age (SD) was 68 (15). Seven were transfers, and 4 had an in-hospital stroke. Of the 8 community-onset strokes, 7 utilized EMS. Mental status changes occurred in 11 of 12 and ocular disturbances in all patients. Time to radiologic diagnosis averaged 1.9 (median = 1.1) days. One patient received tPA. Eight received care in the ICU. Four were intubated. Average LOS was 8.3 days. Four were discharged home, 3 entered inpatient rehabilitation facilities, and 5 entered skilled nursing facilities. In-hospital stroke status further complicates the already challenging diagnosis of AOP infarct, and clinicians must maintain a high suspicion for this rare stroke in order to quickly diagnose and intervene.

BACKGROUND: The focus for reducing hypertension-related cardiovascular disease is the management of blood pressure. Limited data are available on the potential benefit of delaying the onset of hypertension. METHODS: Stroke-free Black and White participants from the REGARDS cohort study (Reasons for Geographic and Racial Differences in Stroke; recruited 2003–2007) were followed through 2022 for incident stroke events. Participants were stratified by duration of recognized hypertension: normotensive (0 years), ≤5 years, 6 to 20 years, or 21+ years. The baseline systolic blood pressure (SBP), the number of classes of antihypertensive medications, and the risk of incident stroke were assessed by duration strata adjusting for demographics, cerebrovascular risk factors, SBP, and use of antihypertensive medications (where appropriate). RESULTS: Of 30 239 study participants, we included 27 310 participants (mean age, 65 years; 45% male), followed a median of 12.4 years, during which 1763 incident stroke events occurred. On average, participants with hypertension duration ≤5 years, 6 to 20 years, and 21+ years were taking 1.68 (95% CI, 1.65–1.71), 2.04 (95% CI, 2.01–2.07), and 2.28 (95% CI, 2.25–2.31) classes of antihypertensive medications, respectively. The adjusted mean SBP level was higher with each increasing duration of recognized hypertension (0, ≤5, 6–20, and 21+ years): 123.9 mm Hg (95% CI, 123.3–124.6), 129.7 mm Hg (95% CI, 129.1–130.2), 131.7 mm Hg (95% CI, 130.6–131.5), and 132.6 mm Hg (95% CI, 132.0–133.1). Compared with normotensive individuals, the hazard for incident stroke increased from 1.31 (95% CI, 1.05–1.63) for ≤5 years duration, 1.50 (95% CI, 1.21–1.87) for 6 to 20 years duration, and 1.67 (95% CI, 1.32–2.10) for 21+ years duration. CONCLUSIONS: Longer duration of recognized hypertension was associated with more classes of antihypertensive medications, higher mean SBP, and higher stroke risk even after adjustment for age and SBP. Collectively, this suggests that delaying the onset of hypertension could reduce the burden of stroke.

Importance: Telestroke has the potential to revolutionize acute stroke treatment by improving access to optimal stroke care, including time-sensitive care such as thrombolysis. However, it is unclear how treatment times and stroke outcomes compare between patients evaluated and not evaluated by telestroke.Objective: To evaluate the association between telestroke use and acute stroke treatment times and outcomes.Design, Setting, and Participants: This retrospective cohort study included patients with acute ischemic stroke aged 18 years or older presenting to 42 Paul Coverdell Michigan Stroke Registry hospitals from January 1, 2022, to December 31, 2023. All patients were potentially eligible for thrombolysis (ie, presented ≤4 hours of last known well, no contraindications to thrombolysis documented).Exposure: Telestroke (vs nontelestroke) encounter.Main Outcomes and Measures: The primary outcomes were receipt of thrombolysis and door-to-needle (DTN) time as a continuous variable and a categorical variable (≤60 vs >60 minutes). Secondary outcomes included discharge ambulatory status, discharge destination, and door-in-door-out (DIDO) time in transferred patients. Multivariable hierarchical models evaluated associations between telestroke (vs nontelestroke) activation and outcomes, sequentially adjusting for demographics, medical history, presentation or arrival, and hospital characteristics.Results: Among the 3036 patients with acute ischemic stroke potentially eligible for thrombolysis (mean [SD] age, 69.7 [14.5] years; 1563 male [51.5%]), 785 (25.9%) were evaluated using telestroke and 2251 (74.1%) without telestroke. A total of 1673 patients (55.1%) were treated with thrombolysis. In the fully adjusted models, patients evaluated by telestroke had a significantly higher odds of receiving thrombolysis (adjusted odds ratio, 1.61; 95% CI, 1.17-2.23) but longer DTN times (6.55 minutes longer; 95% CI, 2.12-10.97 minutes longer) and lower odds of meeting a guideline-concordant DTN time within 60 minutes (adjusted odds ratio, 0.56; 95% CI, 0.39-0.81) compared with those not evaluated by telestroke. Among 255 patients who underwent interhospital transfer, 207 (81.2%) received thrombolysis, and patients with telestroke had significantly longer DIDO times (46.90 minutes longer, 95% CI, 1.08-92.72 minutes longer).Conclusions and Relevance: In this cohort study of patients with acute ischemic stroke potentially eligible for thrombolysis, those evaluated by telestroke had a 61% higher odds of receiving thrombolysis but a 44% lower odds of meeting guideline-concordant DTN times within 60 minutes and prolonged DIDO times compared with those not evaluated by telestroke. Future research should investigate modifiable factors that contribute to treatment delays in patients with ischemic stroke evaluated via telestroke.

Poverty is associated with greater stroke incidence. The relationship between poverty and stroke recurrence is less clear. In this population-based study, incident strokes within the Greater Cincinnati/Northern Kentucky region were ascertained during the 2015 study period and followed up for recurrence until December 31, 2018. The primary exposure was neighborhood socioeconomic status (nSES), defined by the percentage of households below the federal poverty line in each census tract in 4 categories (≤5%, >5%-10%, >10%-25%, >25%). Poisson regression models provided recurrence rate estimates per 100,000 residents using population data from the 2015 5-year American Community Survey, adjusting for age, sex, and race. In a secondary analysis, Cox models allowed for the inclusion of vascular risk factors in the assessment of recurrence risk by nSES among those with incident stroke. Of 2,125 patients with incident stroke, 245 had a recurrent stroke during the study period. Poorer nSES was associated with increased stroke recurrence, with rates of 12.5, 17.5, 25.4, and 29.9 per 100,000 in census tracts with ≤5%, >5%-10%, >10%-25%, and >25% below the poverty line, respectively (p < 0.01). The relative risk (95% CI) for recurrent stroke among Black vs White individuals was 2.54 (1.91-3.37) before adjusting for nSES, and 2.00 (1.47-2.74) after adjusting for nSES, a 35.1% decrease. In the secondary analysis, poorer nSES (HR 1.74, 95% CI 1.10-2.76 for lowest vs highest category) and Black race (HR 1.31, 95% CI 1.01-1.70) were both independently associated with recurrence risk, though neither retained significance after full adjustment. Age, diabetes, and left ventricular hypertrophy were associated with increased recurrence risk in fully adjusted models. Residents of poorer neighborhoods had a dose-dependent increase in stroke recurrence risk, and neighborhood poverty accounted for approximately one-third of the excess risk among Black individuals. These results highlight the importance of poverty, race, and the intersection of the 2 as potent drivers of stroke recurrence.