Tracy E. Madsen

BACKGROUND: The burden of stroke is unequally distributed in the United States, with Black individuals experiencing more incident stroke. It remains unclear whether Black individuals also experience worse stroke recovery. We sought to study disparities in longitudinal functional outcome after acute ischemic stroke in a population-based study. METHODS: We conducted a retrospective cohort study in the Greater Cincinnati Northern Kentucky region over an 18-month period (July 2019 to December 2020). All acute ischemic stroke events were captured. The modified Rankin Scale scores were determined at discharge, 3, 6, and 12 months for patients who survived the index event. We studied the association between Black race and longitudinal modified Rankin Scale (across all time points) with mixed-effects ordinal regression, initially adjusting for age, sex, and time since stroke. Hierarchical regression was used to sequentially adjust for stroke severity and management, premorbid health, and social determinants. RESULTS: Among 2796 patients with acute ischemic stroke (mean age, 69.0; 31% Black; 52% female), 2537 survived and were included (mean age, 68.4; 32% Black; 52% female). Black race was associated with a worse longitudinal modified Rankin Scale score (cOR, 2.61 [95% CI, 1.89–3.60]). Excluding patients with recurrent events did not change this association (cOR, 2.69 [95% CI, 1.92–3.78]). Adding variables reflecting initial stroke severity and management partly attenuated the association (cOR, 1.92 [95% CI, 1.43–2.60]). Adding variables reflecting premorbid health further attenuated the association (cOR decreased to 1.43 [95% CI, 1.09–1.87]). The remaining association between Black race and the modified Rankin Scale score was fully attenuated by social determinants, with cOR, 1.09 (95% CI, 0.80–1.47). There was no interaction between race and time since stroke. CONCLUSIONS: Starting at discharge and persisting out to 12 months, acute ischemic stroke functional outcomes are worse among Black individuals. These disparities are significantly attenuated by clinical factors and social determinants; future studies should explore whether the social determinants can be intervened upon in the recovery period.

Background and ObjectivesMigraine is a known risk factor for stroke in women of reproductive age, although its relationship with stroke among postmenopausal women remains unclear. We assessed the a...

BACKGROUND: Despite significant improvements in early reperfusion, many patients with acute ischemic stroke with large vessel occlusion experience poor outcomes, which indicates a clear need for adjunct therapies. RNS60 is a proprietary combination of oxygen supersaturated in saline with cerebroprotective and immunomodulatory effects. RNS60 showed therapeutic promise in rodent and nonhuman primate models of acute ischemic stroke. RESCUE (A Randomized, Blinded, Placebo-controlled, Parallel Group Design to Determine the Safety of RNS60 in Large Vessel Occlusion Stroke Patients Undergoing Endovascular Thrombectomy) was the proof-of-concept trial testing adjunctive treatment with RNS60 in patients with acute ischemic stroke with large vessel occlusion undergoing endovascular thrombectomy with or without prior treatment with an intravenous thrombolytic. METHODS: This randomized multicenter, placebo-controlled, double-blind, phase 2 study enrolled 82 participants, assigned 1:1:1 to 48-hour infusion of RNS60 0.5 mL/kg per hour, RNS60 1.0 mL/kg per hour, or placebo 1.0 mL/kg per hour, and followed for 90 days. Rates of serious adverse events and mortality were the primary end points. Efficacy end points included the modified Rankin Scale score, infarct volume growth, National Institutes of Health Stroke Scale, worsening of stroke, Barthel Index, and the EuroQoL health-related quality of life scale. RESULTS: The RNS60 groups met the primary end points with similar rates of serious adverse events (33.3%, 25.0%, and 28.6%) and fewer deaths (6.7%, 8.3%, and 14.3%) across RNS60 0.5 mL/kg per hour, RNS60 1.0 mL/kg per hour, and placebo, respectively. The RNS60 1.0 mL/kg per hour group showed reduced infarct growth by 47% at 48 hours post–endovascular thrombectomy (21.4 mL [interquartile range, 5.0–29.1] versus 40.6 mL [interquartile range, 6.3–62.3]; P <0.05). No statistically significant differences were observed in other efficacy end points, but a higher proportion of participants in the RNS60 1.0 mL/kg per hour group had reduced disability (modified Rankin Scale score of 0–2) and functional independence (Barthel Index ≥95) on Day 90. CONCLUSIONS: RNS60 was safe and well tolerated. The RNS60 1.0 mL/kg per hour reduced infarct growth after endovascular thrombectomy compared with placebo. This suggests a benefit warranting investigation in a larger, appropriately powered trial. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT04693715.

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.

Understanding the current status of and temporal trends of stroke epidemiology by age, race, and stroke subtype is critical to evaluate past prevention efforts and to plan future interventions to eliminate existing inequities. We investigated trends in stroke incidence and case fatality over a 22-year time period. In this population-based stroke surveillance study, all cases of stroke in acute care hospitals within a 5-county population of southern Ohio/northern Kentucky in adults aged ≥20 years were ascertained during a full year every 5 years from 1993 to 2015. Temporal trends in stroke epidemiology were evaluated by age, race (Black or White), and subtype (ischemic stroke [IS], intracranial hemorrhage [ICH], or subarachnoid hemorrhage [SAH]). Stroke incidence rates per 100,000 individuals from 1993 to 2015 were calculated using US Census data and age-standardized, race-standardized, and sex-standardized as appropriate. Thirty-day case fatality rates were also reported. Incidence rates for stroke of any type and IS decreased in the combined population and among White individuals (any type, per 100,000, 215 [95% CI 204-226] in 1993/4 to 170 [95% CI 161-179] in 2015, p = 0.015). Among Black individuals, incidence rates for stroke of any type decreased over the study period (per 100,000, 349 [95% CI 311-386] in 1993/4 to 311 [95% CI 282-340] in 2015, p = 0.015). Incidence of ICH was stable over time in the combined population and in race-specific subgroups, and SAH decreased in the combined groups and in White adults. Incidence rates among Black adults were higher than those of White adults in all time periods, and Black:White risk ratios were highest in adults in young and middle age groups. Case fatality rates were similar by race and by time period with the exception of SAH in which 30-day case fatality rates decreased in the combined population and White adults over time. Stroke incidence is decreasing over time in both Black and White adults, an encouraging trend in the burden of cerebrovascular disease in the US population. Unfortunately, however, Black:White disparities have not decreased over a 22-year period, especially among younger and middle-aged adults, suggesting the need for more effective interventions to eliminate inequities by race.

BACKGROUND: Women with a history of stroke represent a vulnerable patient population due to their extant disability, morbidity, and risk of recurrence. The association between prior stroke with patient experience and perception of emergency medical care is unknown. METHODS: We utilized data from the Health Care Experiences and Perception cross-sectional, online survey from the American Heart Association Research Goes Red Registry. Ordinal logistic regression models were performed to assess the association between a self-reported history of stroke in the prior 10 years and the perception of not receiving adequate care in an emergency department because of gender or race. Models were adjusted for age at the time of enrollment, race/ethnicity, myocardial infarction within 10 years, and current smoking status. RESULTS: A total of 3498 women participants met inclusion criteria: 89 participants with a history of stroke in the past 10 years (mean age, 49.4 years; 10.1% Black participants and 5.6% Hispanic participants) and 3409 participants without such history (mean age, 45.8 years; 7.8% Black participants and 7.0% Hispanic participants). In multivariate logistic regression models, stroke history was significantly associated with greater odds of answering “to a great extent” that “I will not receive adequate care in an emergency room based on my gender” (odds ratio, 3.23 [95% CI, 1.69–6.17]) and “…race/ethnicity” (odds ratio, 3.88 [95% CI, 1.45–10.39]). Similar results were seen for secondary outcomes. CONCLUSIONS: Women patients with a stroke history felt less likely to receive adequate emergency care based on gender and race/ethnicity. Whether these negative health perceptions are associated with delays in presentation for stroke or other time-sensitive conditions should be the focus of future studies, given that these populations are known to less frequently receive advanced therapies for stroke, in part due to delays in presentation.