Validation of Early Prognostic Data for Recovery Outcome After Stroke for Future, Higher Yield Trials

Inclusion Criteria:

1. Age 18 years or older

2. Unilateral symptomatic stroke due to ischemia. (Note: Bilateral acute stroke ispermitted if the stroke that is contralateral to the index stroke is asymptomatic).

3. Motor deficits in the acutely affected UE, defined as a Shoulder Abduction andFinger Extension (SAFE) score ≤ 8 out of 10 points20,61 (i.e., excluding full ornearly full motor strength in both shoulder abduction and finger extension) within 48 to 96 hours of stroke onset (or time last known well). a. Please note that, if significant imbalance is observed in SAFE score or MEP+rates, the enrollment threshold for SAFE score may be updated with a formal studymemo.

4. Provision of signed and dated informed consent form within 24 to 96 hours of strokeonset, (or time last known well). Note: Participant is considered "enrolled" uponstarting TMS (at least one stimulation is delivered) or starting study-specific MRIpulse sequence (at least one MRI beep occurs)

5. Stated willingness to comply with all study procedures and availability for theduration of the study, including Day 90 visit which must occur in-person.

6. Fluent in study approved languages (i.e., English or Spanish)

Exclusion Criteria:

1. UE injury or conditions on paretic side that limited use prior to the stroke

2. Legally blind

3. Dense sensory loss on paretic side indicated by a score of 2 on NIHSS sensory item

4. Unable to abduct the shoulder or extend the fingers of the non-paretic UE on verbalcommand

5. Isolated cerebellar stroke

6. Symptomatic stroke in any location within 30 days prior to index stroke.

7. Co-enrollment in a trial of an intervention targeting the incident stroke (acutetreatment or rehabilitation/recovery intervention) after baseline assessments forVERIFY are initiated

8. Known or expected inability to maintain follow-up with study procedures through 90days

9. Cognitive or communication impairment precluding informed consent by theparticipant.

10. Major medical, neurological, or psychiatric condition that would substantiallyaffect functional status

11. Non-cerebrovascular diagnosis associated with unlikely survival at 90 days

12. Pregnancy

13. Contraindication to noncontrast MRI (certain metallic implants, metallic foreignbodies or severe claustrophobia)

14. Contraindication to TMS

15. Implanted electronic cardiac devices (e.g., Automatic ImplantableCardioverter-Defibrillator [AICD] or pacemaker)

16. Any electronic devices in the body at or above the level of the seventhcervical vertebra (such as cochlear implant, cortical stimulator, deep brainstimulator, vagus nerve stimulator, cervical spine epidural stimulator, orventriculoperitoneal shunt)

17. Ferromagnetic intracranial metallic implant

18. Skull defect related to current stroke

19. Seizure after onset of current stroke

20. Seizure within the last 12 months while taking anti-epileptic medications

21. Previous serious adverse reaction to TMS

22. Anticipated inability to perform study procedures within 168 hours of symptom onset

23. Unable to perform behavioral assessments within 48-120 hours of symptom onset (or time last known well).

24. Unable to receive TMS within 72-168 hours or get MRI within 48-168 hours ofsymptom onset (or time last known well).