Showing papers by "Pooja Khatri published in 2012"
TL;DR: Stroke incidence rates in those 20–54 years of age were significantly increased in both black and white patients in 2005 compared to earlier periods, and trends toward increasing stroke incidence at younger ages were found.
Abstract: Objectives: We describe temporal trends in stroke incidence stratified by age from our population-based stroke epidemiology study. We hypothesized that stroke incidence in younger adults (age 20–54) increased over time, most notably between 1999 and 2005. Methods: The Greater Cincinnati/Northern Kentucky region includes an estimated population of 1.3 million. Strokes were ascertained in the population between July 1, 1993, and June 30, 1994, and in calendar years 1999 and 2005. Age-, race-, and gender-specific incidence rates with 95 confidence intervals were calculated assuming a Poisson distribution. We tested for differences in age trends over time using a mixed-model approach, with appropriate link functions. Results: The mean age at stroke significantly decreased from 71.2 years in 1993/1994 to 69.2 years in 2005 ( p p = 0.002), characterized as a shift to younger strokes in 2005 compared with earlier study periods. Stroke incidence rates in those 20–54 years of age were significantly increased in both black and white patients in 2005 compared to earlier periods. Conclusions: We found trends toward increasing stroke incidence at younger ages. This is of great public health significance because strokes in younger patients carry the potential for greater lifetime burden of disability and because some potential contributors identified for this trend are modifiable.
624 citations
TL;DR: In this article, the authors provided recommendations on the use of antithrombotic therapy in patients with stroke or transient ischemic attack (TIA), based on high (A), moderate (B), and low (C) quality evidence.
384 citations
TL;DR: Recent trials testing the safety and efficacy of a thrombin inhibitor (dabigatran) and 2 factor Xa inhibitors (rivaroxaban and apixaban) in preventing stroke in patients with AF are reviewed, and management recommendations are revised.
Abstract: The rate of stroke among adults with atrial fibrillation (AF) varies widely, ranging between 1% and 20% annually (mean 4.5% per year) depending on comorbidities and a patient’s history of prior cerebrovascular events.1 Stratification of stroke risk is important, because the major risk of antithrombotic medications used to lower the incidence of AF-related stroke is bleeding. For warfarin, this involves balancing a bleeding risk of 1% to 12% per year against the risk of ischemic events, with its use generally reserved for individuals at greatest thromboembolic risk.1–3 The advent of several new antithrombotic agents offers alternatives to warfarin and may lower the threshold for thromboembolic risk for initiating therapy in patients with AF.
In this update to the American Heart Association/American Stroke Association (AHA/ASA) “Guidelines for the Primary Prevention of Stroke”4 and the prevention of stroke in patients with stroke or transient ischemic attack (TIA),5 we review recent trials testing the safety and efficacy of a thrombin inhibitor (dabigatran) and 2 factor Xa inhibitors (rivaroxaban and apixaban) in preventing stroke in patients with AF, and we revise management recommendations.4,5 Recommendations follow the AHA’s and the American College of Cardiology’s methods of classifying the level of certainty of the treatment effect and the class of evidence (Table 1).
View this table:
Table 1.
Applying Classification of Recommendations and Level of Evidence
### Risk Stratification
The absolute risk of stroke varies 20-fold among AF patients according to age and associated vascular comorbidities. Several stroke risk stratification schemes have been developed and validated.6–8 These, however, can yield differing results.9 Current AHA guidelines use the CHADS2 stratification scheme7 (CHADS2 is an acronym for Congestive heart failure, Hypertension, Age ≥75 years, Diabetes mellitus, and prior Stroke or TIA). The CHADS2 score was derived from independent …
265 citations
TL;DR: The focus should be on improving stroke awareness, transport to facilities with ability to administer thrombolysis, and familiarity of physicians with acute ischemic stroke treatment guidelines to improve recombinant tissue-type plasminogen activator administration rates.
Abstract: Background and Purpose—The publication of the European Cooperative Acute Stroke Study (ECASS III) expanded the treatment time to thrombolysis for acute ischemic stroke from 3 to 4.5 hours from symptom onset. The impact of the expanded time window on treatment rates has not been comprehensively evaluated in a population-based study. Methods—All patients with an ischemic stroke presenting to an emergency department during calendar year 2005 in the 17 hospitals that compromise the large 1.3 million Greater Cincinnati/Northern Kentucky population were included in the analysis. Criteria for exclusion from thrombolytic therapy are analyzed retrospectively for both the standard and expanded timeframes with varying door-to-needle times. Results—During the study period, 1838 ischemic strokes presenting to an emergency department were identified. A small proportion of them arrived in the expanded time window (3.4%) compared with the standard time window (22%). Only 0.5% of those who arrived in this timeframe met el...
146 citations
TL;DR: Patients with mild ischemic stroke have substantial rates of disability at 90 days, and early worsening and acute infarct growth from baseline to 5 days were more common among those with poor outcome.
Abstract: Background and Purpose—Prior studies have shown that patients with mild ischemic stroke have substantial disability rates at hospital discharge. We sought to determine disability rates at 90 days among patients not treated with thrombolytic therapy and explore the role of early neurological worsening. Methods—We reviewed a prospective cohort of 136 consecutive patients with mild deficits (National Institutes of Health Stroke Scale score ≤5) presenting within 24 hours of onset and no baseline disability. Baseline MRIs were performed on all subjects. Five-day MRIs were performed on a prespecified subcohort. Results—Among 136 patients, 40 (29%; 95% CI, 22%–38%) had poor outcomes (modified Rankin Scale score 2–6) at 90 days. Early worsening (4-point National Institutes of Health Stroke Scale increase; 25% versus 1%, P 10% on MRI–diffusion-weighted imaging; 79% versus 53%, P=0.02) from baseline to 5 days were more common among those with poor outcome. Conclusions—Patients with...
144 citations
TL;DR: The observed increase in substance abuse is contributing to the increased incidence of stroke in young adults and patients aged younger than 55 years who experience a stroke should be routinely screened and counseled regarding substance abuse.
Abstract: Background and Purpose—Approximately 5% of strokes occur in adults aged 18 to 44 years. Substance abuse is a prevalent risk factor for stroke in young adults. We sought to identify trends in substance abuse detection among stroke patients. Methods—Using a population-based design, we sought to identify all patients aged 18 to 54 years experiencing a stroke (ischemic or hemorrhagic) in the Greater Cincinnati and Northern Kentucky Study region during 1993 to 1994, 1999, and 2005. Demographic and clinical characteristics and substance use data were obtained retrospectively from chart review and adjudicated by physicians. Results—The number of young patients identified with a stroke increased from 1993 to 1994 (297) to 2005 (501). Blacks (61% vs 51%; P<0.02) and men (61% vs 47%; P<0.002) reported substance abuse (current smoking, alcohol, or illegal drug use) more frequently than did whites and women. Overall use of substances increased across study periods, 45% in 1993 versus 62% in 2005 (P=0.003). The trend ...
114 citations
TL;DR: Until further technical and imaging advances can incorporate real-time reliable perfusion studies in the angio-suite to delineate regional perfusion more accurately, the TICI grading system is the best defined and most widely used scheme.
Abstract: Background: Recanalization and angiographic reperfusion are key elements to successful endovascular and interventional acute ischemic stroke (AIS) therapy. Intravenous recombinant tissue plasminogen activator (rt-PA), the only established revascularization therapy approved by the US Food & Drug Administration for AIS, may be less effective for large artery occlusion. Thus, there is enthusiasm for endovascular revascularization therapies, which likely provide higher recanalization rates, and trials are ongoing to determine clinical efficacy and compare various methods. It is anticipated that clinical efficacy will be well correlated with revascularization of viable tissue in a timely manner. Method: Reporting, interpretation, and comparison of the various revascularization grading methods require agreement on measurement criteria, reproducibility, ease of use, and correlation with clinical outcome. These parameters were reviewed by performing a Medline literature search from 1965 to 2011. This review critically evaluates current revascularization grading systems. Results and Conclusion: The most commonly used revascularization grading methods in AIS interventional therapy trials are the thrombolysis in cerebral ischemia (TICI, pronounced “tissy”) and thrombolysis in myocardial ischemia (TIMI) scores. Until further technical and imaging advances can incorporate real-time reliable perfusion studies in the angio-suite to delineate regional perfusion more accurately, the TICI grading system is the best defined and most widely used scheme. Other grading systems may be used for research and correlation purposes. A new scale that combines primary site occlusion, lesion location, and perfusion should be explored in the future.
63 citations
TL;DR: The proportion of patients with ischemic stroke without significant baseline disability with large middle cerebral artery infarction who would have been potentially eligible for hemicraniectomy in an era before publication of recent hemicaniectomy trials is determined.
Abstract: Background and Purpose—Malignant middle cerebral artery infarction is estimated to occur in 10% of ischemic strokes, but few patients undergo decompressive hemicraniectomy, a proven therapy. We determined the proportion of patients with ischemic stroke without significant baseline disability with large middle cerebral artery infarction who would have been potentially eligible for hemicraniectomy in an era before publication of recent hemicraniectomy trials. Methods—Ischemic stroke cases that occurred in 2005 among residents of the 5-county Greater Cincinnati/Northern Kentucky area were ascertained. Two study physicians reviewed all clinical and neuroimaging data for patients with baseline modified Rankin Scale score 50% of the middle cerebral artery territory or >145 mL on diffusion-weighted MRI. Other eligibility criteria for hemicraniectomy, based on the pooled analysis of...
43 citations
TL;DR: It was found that increasing community poverty was associated with worse stroke severity at presentation, independent of other known factors associated with stroke outcomes.
Abstract: Background and Purpose—Initial stroke severity is one of the strongest predictors of eventual stroke outcome. However, predictors of initial stroke severity have not been well-described within a population. We hypothesized that poorer patients would have a higher initial stroke severity on presentation to medical attention. Methods—We identified all cases of hospital-ascertained ischemic stroke occurring in 2005 within a biracial population of 1.3 million. “Community” socioecomic status was determined for each patient based on the percentage below poverty in the census tract in which the patient resided. Linear regression was used to model the effect of socioeconomic status on stroke severity. Models were adjusted for race, gender, age, prestroke disability, and history of medical comorbidities. Results—There were 1895 ischemic stroke events detected in 2005 included in this analysis; 22% were black, 52% were female, and the mean age was 71 years (range, 19–104). The median National Institutes of Health S...
41 citations
TL;DR: Both current symptoms and lifetime history of depression predicted poor functional outcomes and poor quality of life at 3 and 12 months, after adjustment for age, race, sex, prior stroke, baseline functional status, and stroke severity.
36 citations
Medical College of Wisconsin1, University of Texas at Austin2, University of Alabama3, Saint Louis University4, University of California, San Francisco5, Cornell University6, Wake Forest Baptist Medical Center7, Cleveland Clinic8, University of Cincinnati9, University of California, Los Angeles10, Boston University11, Wayne State University12, University of Miami13
TL;DR: This document was developed to review current clinical efficacy of pharmacologic and mechanical revascularization therapy, selection criteria, periprocedure management, and endovascular time metrics and to highlight current practice patterns and provide an outline for the future development of multisociety guidelines and recommendations.
Abstract: Guidelines have been established for the management of acute ischemic stroke; however, specific recommendations for endovascular revascularization therapy are lacking. Burgeoning investigation of endovascular revascularization therapies for acute ischemic stroke, rapid device development, and a diverse training background of the providers performing the procedures underscore the need for practice recommendations. This review provides a concise summary of the Society of Vascular and Interventional Neurology endovascular acute ischemic stroke roundtable meeting. This document was developed to review current clinical efficacy of pharmacologic and mechanical revascularization therapy, selection criteria, periprocedure management, and endovascular time metrics and to highlight current practice patterns. It therefore provides an outline for the future development of multisociety guidelines and recommendations to improve patient selection, procedural management, and organizational strategies for revascularization therapies in acute ischemic stroke.
TL;DR: IAT does not appear to increase the risk of in-hospital mortality among those aged >80 years compared with IV thrombolysis alone and endovascular therapy alone versus IV rtPA.
Abstract: Background and Purpose—Few studies have addressed outcomes among patients ≥80 years treated with acute stroke therapy. In this study, we outline in-hospital outcomes in (1) patients ≥80 years compared with their younger counterparts; and (2) those over >80 years receiving intra-arterial therapy (IAT) compared with those treated with intravenous recombinant tissue-type plasminogen activator (IV rtPA). Methods—Stroke centers within the Specialized Program of Translational Research in Acute Stroke (SPOTRIAS) prospectively collected data on all patients treated with IV rtPA or IAT from January 1, 2005, to December 31, 2010. IAT was defined as receiving any endovascular therapy; IAT was further divided into bridging therapy when the patient received both IAT and IV rtPA and endovascular therapy alone. In-hospital mortality was compared in (1) all patients aged ≥80 years versus younger counterparts; and (2) IAT, bridging therapy, and endovascular therapy alone versus IV rtPA only among those age ≥80 years using...
TL;DR: Only one third of patients with AIS treated with antihypertensives met American Heart Association-recommended treatment criteria, and the rate of change of BP was frequently greater than recommended.
Abstract: Background and Purpose—Severely elevated blood pressure (BP) and aggressive BP reduction are both associated with poor outcome in acute ischemic stroke (AIS). In nontissue-type plasminogen activator patients, the American Heart Association recommends antihypertensive therapy only if BP is ≥220/120 mm Hg with a goal of 15% to 25% reduction in the first 24 hours. We hypothesized that patients with AIS often receive antihypertensives in the emergency department below the recommended threshold and that BP reduction is often >20%. Methods—In 2005, AIS cases were ascertained at all 16 hospitals in Greater Cincinnati. BP was recorded at emergency department presentation and before and after antihypertensive treatment. Hypertension was defined as BP ≥220/120 mm Hg. Chi-square and Mann-Whitney U tests were used for comparisons. Results—A total of 1739 patients with AIS met inclusion criteria. Median age was 72 years with 43% male and 25% black. Of 218 treated with antihypertensives, 65 (30.0%) met treatment criter...
TL;DR: Hematoma and lesion volumes in subjects with symptomatic parenchymal hematoma (sPH) treated with combined IV and intra-arterial (IA) rtPA in the Interventional Management of Stroke (IMS) studies were compared and the use of PH2 as a sole surrogate for sPH in studies of stroke treatment may underestimate the incidence of clinically significant hemorrhage.
Abstract: Background and purpose A positive correlation between large parenchymal hematoma (PH) volume and large CT lesion volume in subjects treated with intravenous (IV) recombinant tissue plasminogen activator (rtPA) as well as placebo controls was identified in the European Cooperative Acute Stroke Study II (ECASS II). A study was undertaken to examine the relationship between PH volume and total lesion volume (including both cerebral infarction and hemorrhage) in subjects with symptomatic parenchymal hematoma (sPH) treated with combined IV and intra-arterial (IA) rtPA in the Interventional Management of Stroke (IMS) studies. Methods Hematoma and lesion volumes were measured planimetrically and by the ABC/2 method in 105 subjects from IMS studies I and II following combined IV and IA rtPA treatment. PH type 1 or 2 was determined by dichotomizing at >30% of lesion volume. Hematoma and lesion volumes for both symptomatic PH1 (sPH1) and PH2 (sPH2) types were compared using both measurement methods. Both sPH types were compared for baseline NIH Stroke Score, baseline Alberta Stroke Program Early CT score and treatment revascularization score based on the planimetric volume method. Results The volume of sPH1 and sPH2 did not differ by either method of measurement. Subjects with sPH2 had a lower lesion volume compared with all PH1 (p=0.004) and sPH1 (p=0.02) by both methods. The ABC/2 method overestimated PH volume by 55±33% and lesion volume by 34±22% for sPH compared with the planimetric method. Conclusions In IMS I and II, hemorrhages in subjects with sPH2 were similar in volume to those in subjects with sPH1 and were associated with a smaller rather than a larger total lesion volume compared with other PH in the setting of combined IV/IA therapy. The use of PH2 as a sole surrogate for sPH in studies of stroke treatment may underestimate the incidence of clinically significant hemorrhage.
TL;DR: It is hypothesized that finding embolus within the external carotid artery on angiography in stroke patients with internal carotids occlusion allows confident ascription to a proximal, usually cardiac, source.
Abstract: Arteriograms performed in the Interventional Management of Stroke studies were analyzed for external carotid artery embolus. Two cases were identified and diagnosed as thromboembolic due to a cardiac origin. This is an uncommon but useful finding on angiography which is helpful for further management. It is hypothesized that finding embolus within the external carotid artery on angiography in stroke patients with internal carotid artery occlusion allows confident ascription to a proximal, usually cardiac, source.
Journal Article•
TL;DR: Frailty was associated with increased in-hospital mortality, poorer outcome at discharge (mRS≥3) and decreased likelihood of being discharged home, which suggest that frailty may represent a biological rather than chronological measure of aging.
Abstract: Background: There is little research that examines the impact of frailty on stroke outcomes. The objective of our study was to develop a frailty index (FI) and analyze its relationship to stroke ou...
Journal Article•
TL;DR: Clinically, these results suggest an opportunity to improve HRQoL among stroke survivors with effective spasticity management, and cross-sectionally compared using generalized linear models.
Abstract: Background: Spasticity can lead to numerous symptomatic and functional problems that can cause substantial disability. No published studies have quantified the independent effect spasticity has on the health-related quality of life (HRQoL) of stroke survivors. Objective: To assess the hypothesis that spasticity has a negative impact on HRQoL among stroke survivors. Design: In 2005, as part of the Greater Cincinnati/Northern Kentucky Stroke Study, a cohort of 460 ischemic stroke patients were interviewed during hospitalization and then followed over time. Detailed in-person interviews and medical record abstractions were undertaken during the early post-stroke period to capture key information about demographics; pre-stroke level of functioning; social, family, and medical histories; medications; laboratory results; and stroke severity. Follow-up interviews at 3 months, 1 year, and 2 years gathered information on HRQoL as measured by the Short Form-12 (SF-12), EuroQol-5D (EQ-5D), and Stroke Specific Quality of Life (SSQOL). SF-12 scores are divided into mental (MCS) and physical (PCS) components that range from 0 to 100, with higher scores indicating better health. EQ-5D scores range from 0 (death) to 1 (perfect health). SSQOL scores are stroke specific and range between 0 and 5, with lower scores indicating better HRQoL. HRQoL differences between stroke survivors with and without spasticity (as reported by the patient) were cross-sectionally compared using generalized linear models, adjusting for age, race, stroke severity, pre-stroke function, and comorbidities. Results: Of the 460 ischemic stroke patients, 328 had spasticity data available at the 3-month interview, with 54 (16%) reporting spasticity following their stroke. The patients included in the 3-month analysis had a mean age of 66 years; 49% were female, and 26% black. Patients who reported spasticity at 3 months had lower mean PCS, EQ-5D index, and SSQOL total score compared with patients without spasticity (Table). Similar differences in HRQoL were also observed at year 1 and year 2 (data not shown). Conclusions: We found statistically and clinically meaningful differences in HRQoL between stroke survivors with and without spasticity at 3 months, 1 year, and 2 years following stroke. Clinically, these results suggest an opportunity to improve HRQoL among stroke survivors with effective spasticity management.
TL;DR: Although the CLEAR trial was successful in meeting its delineated recruitment goals, the findings suggest enrollment could have been more efficient, and eligible patients who were not approached and those treated with recombinant tissue plasminogen activator but not enrolled represent targets for improving enrollment rates.
Abstract: Background Recruitment challenges are common in acute stroke clinical trials. In a population-based study, we determined eligibility and actual enrollment for a successful, phase II acute stroke clinical trial. We hypothesized that missed opportunities for enrollment of eligible patients occurred frequently, despite the success of the trial. Methods In 2005, acute ischemic stroke (AIS) cases in our region were identified at all 17 local hospitals as part of an epidemiologic study. The Combined Approach to Lysis Utilizing Eptifibatide and Recombinant Tissue Plasminogen Activator (CLEAR) trial assessed the safety of this combination in AIS patients within 3 hours of symptom onset. In 2005, we determined the proportion of AIS patients who were eligible for CLEAR and the proportion that were actually enrolled. Results At 8 participating hospitals, 33 (2.8%) of 1175 AIS patients were eligible for CLEAR. Of 33 eligible patients, 18 (54.5%) were approached for enrollment, 4 (12.1%) refused, 1 (3.0%) was not consentable, and 13 (39.4%) were enrolled. Of the 15 not approached for enrollment in the trial, 10 were evaluated by the stroke team; 7 received recombinant tissue plasminogen activator. Enrollment was not associated with night or weekend presentation. Conclusions Although the CLEAR trial was successful in meeting its delineated recruitment goals, our findings suggest enrollment could have been more efficient. Three out of 4 patients approached for enrollment participated in the trial. Eligible patients who were not approached and those treated with recombinant tissue plasminogen activator but not enrolled represent targets for improving enrollment rates.
01 Jan 2012
TL;DR: The literature lacks research relevan... as discussed by the authors stated that most RCTs do not finish on time or on budget of the original proposal, and the literature lacks relevant research relevancy.
Abstract: Purpose: Randomized control trials (RCT) are the gold standard of clinical research, yet most RCTs do not finish on time or on budget of the original proposal. The literature lacks research relevan...
TL;DR: Mechanical embolectomy use has almost doubled in the US over the last three years, and it becomes imperative to establish their effectiveness through definitive clinical trials.
Abstract: Objective: To determine if embolectomy use is increasing over time, and further characterize its use. Background Intravenous thrombolysis is an established acute reperfusion therapy based on randomized trials. Endovascular mechanical embolectomy (using the MERCI or Penumbra devices) is also an option based on single-arm studies, and is reimbursed by Medicare at a higher rate. Randomized trials comparing both approaches are underway. Design/Methods: We reviewed the Premier Database for ischemic stroke hospitalizations (ICD-9 codes 433.x1, 434.x1 and 436) of adult patients during 2008, 2009 and 2010 fiscal years. This database includes all payor sources, and demographic and drug utilization data, from a sampling of 15% of US hospitals. Use of reperfusion therapies was determined through the thrombolysis procedure code (99.10), pharmacy records (use of 50 or 100 mg Alteplase vials), hospital billing information, and/or the mechanical thrombectomy procedure code (39.74). Results: Increasing proportions of ischemic strokes were treated with reperfusion therapies each year: 4.1% (2482/61096) in 2008, 4.7% (2983/63093) in 2009, and 5.4% (3451/63575) in 2010 (p 500 beds; p Conclusions: Mechanical embolectomy use has almost doubled in the US over the last three years. As healthcare resources are increasingly used to treat patients with mechanical embolectomy, it becomes imperative to establish their effectiveness through definitive clinical trials. Supported by: NIH/NINDS K23 NS059843 (PK) and CDC Grant (DOK). Disclosure: Dr. Khatri has received personal compensation for activities with law offices as an expert witness. Dr. Khatri has received research support from Genentech, Inc. and Penumbra, Inc. Dr. Meganathan has nothing to disclose. Dr. Adeoye has received personal compensation for activities with EKR Therapeutics for Speaker9s Bureau and consultant services. Dr. Hornung has nothing to disclose. Dr. Kleindorfer has received personal compensation for activities with Genentech, Inc. and Boehringer Ingelheim Pharmaceuticals, Inc. as a speaker and participant on an advisory board.
Journal Article•
TL;DR: More than half of all ischemic stroke cases have mild symptom severity upon initial presentation, and the monitoring of NIHSS across population sub-groups and by time represents a legitimate target for population-based surveillance efforts.
Abstract: Background: There is little data concerning the distribution of stroke severity in contemporary ischemic stroke populations. Changes in the prevalence of stroke risk factors, as well as in the secondary prevention of stroke could be expected to influence the distribution of stroke severity at the population level . The collection of National Institute of Health Stroke Scale (NIHSS) data are frequently missing in clinical registries, and more complete data are often limited to clinical trial settings which typically include a select patient sample. We describe the distribution of NIHSS across major demographic sub-groups in a nationally representative, population-based study of ischemic stroke. Methods: Within a biracial population of 1.3 million, all strokes among area residents in 2005 were ascertained by screening discharge records at local hospitals and clinics. A sampling scheme was developed to ascertain additional cases in physician offices and nursing homes. All confirmed ischemic stroke cases underwent comprehensive chart abstraction, including generation of a retrospective NIHSS score (range 0 - 42), which described symptom severity on presentation. Descriptive statistics of NIHSS (median, IQR) were generated by demographic subgroup and surveillance location (hospital admission, in-hospital stroke, or out-of-hospital). To account for the sampling design and multiple stroke events within some subjects, statistically significant differences were tested using age-adjusted GEE-based linear models. Results: There were 2210 ischemic stroke cases identified during the 12-month study period. The overall median NIHSS score was 3.0 (IQR 1.0 - 7.0). The distribution of NIHSS by age, sex, race, and surveillance source are summarized in the Table. NIHSS score was statistically significantly higher in older age groups, and also differed significantly by surveillance location. There were no significant differences in NIHSS by sex or race. Conclusions: More than half of all ischemic stroke cases have mild symptom severity upon initial presentation (i.e., NIHSS