Jeffrey M. Katz

Stroke is a leading cause of death and foremost cause of disability in the United States, and extreme heat is the leading weather-related cause of death. We examined the association between ambient temperature and acute ischemic stroke (AIS) admissions in New York State. We leveraged an existing cohort of consecutive AIS admissions presenting to a large healthcare system during a ten-year period (January 2015–December 2024), identified based on discharge diagnosis codes for ischemic stroke. Meteorological data from gridMET (~4 km grids) were used to produce daily averages of maximum temperature (Tmax) for ZIP code tabulation area (ZCTA) boundaries in the New York metropolitan area, linked to residential ZIP codes. Time-stratified case-crossover models with distributed lags (0–1 days) were used to estimate the association between daily maximum temperature (evaluated as a 10 °F increase, 95th percentile temperature vs. median temperature, and 95 °F vs. median temperature) and AIS admissions, both for the entire year and restricted to warm season months of May–October. There were 27,926 AIS admissions from 2015 to 2024. The mean (standard deviation, SD) age was 71.7 (14.4) years, and 13,934 (49.9%) were female, while the mean (SD) Tmax was 62.8 (17.3) °F, and the mean 95th percentile Tmax was 87.9 °F. The relative risk (95% confidence interval) of AIS admissions was strongest on the same day of admission (10 °F increase: 1.041 (1.019, 1.064); 95th percentile: 1.105 (1.047, 1.165); 95 °F: 1.132 (1.059, 1.210), and effects were similar in warm season months. High daily maximum temperatures were associated with an increased risk of AIS admissions, with the highest risk on the same day of admission. These findings support the short-term impact of temperature on AIS admissions and can inform future public health efforts to reduce heat-related AIS risk in affected populations.

Background: The Armadillo (Q'Apel Medical Inc., Fremont, CA) is a novel bimodal guide catheter, combining properties of a long support sheath with a large‐bore distal access catheter, whose stiffness can be adjusted from “track” mode during navigation to “support” mode for intervention. The main objective of this study was to determine the safety and efficacy of the Armadillo for intracranial interventions via the transfemoral approach. Methods: This is a retrospective study of our initial Armadillo experience, composed of all patients who underwent an intracranial intervention using the Armadillo via the transfemoral route, between December 2022 and December 2023, at a single institution. Transvenous, external carotid, and stroke‐related interventions were excluded. Results: Of 62 total interventions with the Armadillo catheter, 58 procedures (53/58 [91.4%] for aneurysms, 3/58 [5.6%] for arteriovenous malformations, and 2/58 [3.4%] for intracranial stenosis) in 55 patients (mean age, 57.2 [standrad deviation (SD), 12.4] years; 46/55 [83.6%] female sex) met study criteria. Most interventions were in the anterior circulation (51/58 [87.9%]) and significant carotid or vertebral artery tortuosity was encountered in 10 of 58 (17.2%) cases. The Armadillo was the primary sheath in 57/58 (98.3%) cases, and 50/58 (86.2%) received vasodilator for vasospasm prophylaxis prior to distal navigation. The Armadillo was successfully navigated to the intended target location in 52 of 58 (89.7%) procedures, predominantly over a macro‐guidewire alone (41/58 [70.7%]). The need for a triaxial system during the intervention was obviated in 36 of 58 (62.1%) procedures, and all interventions were completed successfully without having to exchange for an alternate support catheter. There were no Armadillo‐related complications. Conclusion: The Armadillo was highly effective as a long guide sheath for intracranial interventions via the transfemoral route, with a high rate of successful distal navigation and no device‐related complications.

BACKGROUND: Many national initiatives focus on promoting early hospital arrival of patients with acute ischemic stroke (AIS) because treatment effectiveness is time-dependent. However, several studies reported time-delays in hospital arrival, especially during the COVID-19 pandemic. Our purpose was to evaluate the 10-year trends in last known well to arrival (LKWA) time and assess disparities in patients with AIS. METHODS: A retrospective study of consecutive patients with AIS in the United States admitted to a large, socioeconomically diverse health care system in the New York metropolitan area was performed from 2014 to 2023. LKWA time groups were categorized according to treatment eligibility: 0 to 4.5, >4.5 to 24, and >24 hours. Demographic and clinical characteristics, treatment utilization, and modified Rankin Scale at discharge were extracted from electronic health records. Trend, bivariable, and multivariable logistic regression analyses were conducted. RESULTS: A total of 11 563 patients with AIS were included with 53% (6163) LKWA 0 to 4.5, 34% (3988) LKWA >4.5 to 24, and 12% (1412) LKWA >24 groups. From 2014 to 2023, there was a significant downtrend in the early LKWA 0 to 4.5 (61%–46%) with uptrends in the later LKWA >4.5 to 24 (31%–43%) and LKWA >24 (8%–11%) groups ( P 4.5 groups, the gap widened between racial categories after COVID (2021–2023; P =0.004). Compared with LKWA 0 to 4.5, the LKWA >4.5 to 24 group was less likely to receive endovascular thrombectomy ( P P 4.5 groups were more likely to be older >80 years of age (odds ratio, 1.33 [95% CIs, 1.11–1.58]), men (1.11 [1.03–1.20]), Black patients (1.21 [1.09–1.34]), Asian patients (1.20 [1.03–1.39]), Medicaid insurance (1.18 [1.08–1.29]), and low-income <$80 000 (1.39 [1.20–1.61]). CONCLUSIONS: In the past decade, there was a significant uptrend in patients with AIS arriving in the late LKWA >4.5 groups. Socioeconomic disparities were observed with a persistent uptrend in non-White patients in the late LKWA >4.5 groups after the COVID pandemic. These findings highlight the need to implement targeted efforts to improve disparities in LKWA time in patients with AIS.

Background: Socioeconomically disadvantaged neighborhoods are particularly vulnerable to heat-related illnesses. We aim to investigate the association between the heat vulnerability index (HVI), an established neighborhood-level metric of heat-related mortality risk, and acute ischemic stroke (AIS) severity. Methods: We conducted a retrospective analysis of consecutive AIS admissions to a comprehensive stroke center between 2012 and 2021. Stroke severity was defined upon admission based on the National Institutes of Health Stroke Scale (NIHSS). Demographic, socioeconomic, and clinical characteristics were extracted from electronic health records. HVI status was assigned using residential ZIP codes. Multivariable logistic regression analyses were performed. Results: Of 3429 AIS admissions, 1123 (32.8%) were from high-HVI (scores 4–5) neighborhoods and 868 (25.3%) had severe stroke (NIHSS score ≥ 10). In the multivariable regression model with stepwise selection, a high HVI was independently associated with severe stroke (adjusted odds ratio: 1.40 [95% confidence interval 1.16–1.69]). Conclusions: The association between a high HVI and severe stroke underscores the importance of targeting policy interventions to mitigate heat-related illness in socioeconomically disadvantaged neighborhoods.

Background: The management of patients with initially mild acute ischemic stroke (AIS), defined by the National Institutes of Health Stroke Scale (NIHSS) scores 0–5, remains ambiguous despite advances in stroke treatment. The early identification of patients likely to deteriorate is critical in preventing lasting disability.Aims: We investigated the frequency and early predictors of poor functional outcomes in AIS patients with large-vessel occlusion (LVO) and initial mild deficits.Methods: We performed a retrospective observational study of consecutive AIS patients admitted to a single comprehensive stroke center between 2018 and 2021. The inclusion criteria were a diagnosis of AIS, an arrival NIHSS score of 0–5, imaging-confirmed LVO, and arrival within 24 h of the last-known-well time. The primary outcome was the change in the discharge-modified Rankin Score (ΔmRS) from baseline, categorized as 0–1 (stable outcome) or >1 (poor outcome). Early neurological deterioration was defined as a mean NIHSS score increase of >1 in the first 24-h period. Univariate and multivariable regression analyses were performed. The mean daily NIHSS scores were compared between groups using an analysis of variance (ANOVA).Results: Of 4,410 stroke admissions, 120 patients met the study inclusion criteria, with 71 (59.2%) patients having a ΔmRS of 0–1 and 49 (40.8%) patients having a ΔmRS of > 1. The mean arrival NIHSS score was similar between groups. However, the mean first-24-h NIHSS score was significantly higher in the poor outcome group vs. the stable outcome group (2.13 vs. 0.95, p < 0.001). A demographic-adjusted multivariable logistic regression revealed that a higher mean first-24-h NIHSS score was the sole early predictor of poor outcome (odds ratio [OR] of 1.65 and a 95% confidence interval [CI] of [1.18, 2.48]). The only association with early neurological deterioration was vertebral artery occlusion, with an OR of 0.35 and a 95% CI of [0.14, 0.81]. The trending mean daily NIHSS scores revealed that patients with poor outcomes deteriorate within 24 h, a significant difference from the stable group (p < 0.001).Conclusion: Poor outcomes occurred in a significant proportion of LVO patients with initial mild deficits. The only association was early neurological deterioration. To prevent poor outcomes, rapid identification of any clinical deterioration should prompt consideration of thrombectomy.