Search

Background The aim of the study was to develop and test an artificial intelligence (AI)-based method to improve the quality of [18F]fluorodeoxyglucose (FDG) positron emission tomography (PET) images. Methods A convolutional neural network (CNN) was trained by using pairs of excellent (acquisition time of 6 min/bed position) and standard (acquisition time of 1.5 min/bed position) or sub-standard (acquisition time of 1 min/bed position) images from 72 patients. A test group of 25 patients was used to validate the CNN qualitatively and quantitatively with 5 different image sets per patient: 4 min/bed position, 1.5 min/bed position with and without CNN, and 1 min/bed position with and without CNN. Results Difference in hotspot maximum or peak standardized uptake value between the standard 1.5 min and 1.5 min CNN images fell short of significance. Coefficient of variation, the noise level, was lower in the CNN-enhanced images compared with standard 1 min and 1.5 min images. Physicians ranked the 1.5 min CNN and the 4 min images highest regarding image quality (noise and contrast) and the standard 1 min images lowest. Conclusions AI can enhance [18F]FDG-PET images to reduce noise and increase contrast compared with standard images whilst keeping SUVmax/peak stability. There were significant differences in scoring between the 1.5 min and 1.5 min CNN image sets in all comparisons, the latter had higher scores in noise and contrast. Furthermore, difference in SUVmax and SUVpeak fell short of significance for that pair. The improved image quality can potentially be used either to provide better images to the nuclear medicine physicians or to reduce acquisition time/administered activity.

Contains fulltext : 235277.pdf (Publisher’s version ) (Closed access) BACKGROUND: Balancing the risks of recurrent ischaemic stroke and intracranial haemorrhage is important for patients treated with antithrombotic therapy after ischaemic stroke or transient ischaemic attack. However, existing predictive models offer insufficient performance, particularly for assessing the risk of intracranial haemorrhage. We aimed to develop new risk scores incorporating clinical variables and cerebral microbleeds, an MRI biomarker of intracranial haemorrhage and ischaemic stroke risk. METHODS: We did a pooled analysis of individual-patient data from the Microbleeds International Collaborative Network (MICON), which includes 38 hospital-based prospective cohort studies from 18 countries. All studies recruited participants with previous ischaemic stroke or transient ischaemic attack, acquired baseline MRI allowing quantification of cerebral microbleeds, and followed-up participants for ischaemic stroke and intracranial haemorrhage. Participants not taking antithrombotic drugs were excluded. We developed Cox regression models to predict the 5-year risks of intracranial haemorrhage and ischaemic stroke, selecting candidate predictors on biological relevance and simplifying models using backward elimination. We derived integer risk scores for clinical use. We assessed model performance in internal validation, adjusted for optimism using bootstrapping. The study is registered on PROSPERO, CRD42016036602. FINDINGS: The included studies recruited participants between Aug 28, 2001, and Feb 4, 2018. 15 766 participants had follow-up for intracranial haemorrhage, and 15 784 for ischaemic stroke. Over a median follow-up of 2 years, 184 intracranial haemorrhages and 1048 ischaemic strokes were reported. The risk models we developed included cerebral microbleed burden and simple clinical variables. Optimism-adjusted c indices were 0·73 (95% CI 0·69-0·77) with a calibration slope of 0·94 (0·81-1·06) for the intracranial haemorrhage model and 0·63 (0·62-0·65) with a calibration slope of 0·97 (0·87-1·07) for the ischaemic stroke model. There was good agreement between predicted and observed risk for both models. INTERPRETATION: The MICON risk scores, incorporating clinical variables and cerebral microbleeds, offer predictive value for the long-term risks of intracranial haemorrhage and ischaemic stroke in patients prescribed antithrombotic therapy for secondary stroke prevention; external validation is warranted. FUNDING: British Heart Foundation and Stroke Association.

OBJECTIVE The natural history of patients with stroke and cancer remains poorly understood in the modern era of hyper-acute stroke therapies (recombinant tissue plasminogen activator (tPA) and endovascular clot retrieval (ECR)). Prior to these advances in stroke treatment, a highly cited study reported median overall survival (mOS) 4.5 months after stroke in a cohort of patients with cancer (2004, n=96). Our aim is to evaluate outcome following stroke for patients with cancer in this modern era. Our hypothesis is that patients with stroke and cancer have better outcome than in earlier studies. DESIGN AND SETTING Retrospective analysis of admission to a tertiary Stroke Unit between January 2015 and September 2017 (N=1910), evaluation of hospital records and cancer treatment records. OUTCOME MEASURES Cancer was categorised as early stage (stage I and II) and advanced stage (stage III or IV, using the RD-Staging system). Survival analysis was performed in R. RESULTS There were 143 stroke patients with cancer (62% male) with mean age 73.2 +/- 12.5 years. Ischemic stroke occurred in 74.1% and 45 of 106 patients (42.5%) received intravenous thrombolysis (34/45) and / or endovascular clot retrieval (11/45). One patient who received ECR died within 30-days of stroke. Those with early-stage disease had mOS of 19.6 months (IQR 3.1, 31.5 months) and in advanced stage cancer mOS was 2.5 months (IQR 0.4, 6.3 months, p

Background [18F]-fluorodeoxyglucose (FDG) positron emission tomography with computed tomography (PET-CT) is a well-established modality in the work-up of patients with suspected or confirmed diagnosis of lung cancer. Recent research efforts have focused on extracting theragnostic and textural information from manually indicated lung lesions. Both semi-automatic and fully automatic use of artificial intelligence (AI) to localise and classify FDG-avid foci has been demonstrated. To fully harness AI’s usefulness, we have developed a method which both automatically detects abnormal lung lesions and calculates the total lesion glycolysis (TLG) on FDG PET-CT. Methods One hundred twelve patients (59 females and 53 males) who underwent FDG PET-CT due to suspected or for the management of known lung cancer were studied retrospectively. These patients were divided into a training group (59%; n = 66), a validation group (20.5%; n = 23) and a test group (20.5%; n = 23). A nuclear medicine physician manually segmented abnormal lung lesions with increased FDG-uptake in all PET-CT studies. The AI-based method was trained to segment the lesions based on the manual segmentations. TLG was then calculated from manual and AI-based measurements, respectively and analysed with Bland-Altman plots. Results The AI-tool’s performance in detecting lesions had a sensitivity of 90%. One small lesion was missed in two patients, respectively, where both had a larger lesion which was correctly detected. The positive and negative predictive values were 88% and 100%, respectively. The correlation between manual and AI TLG measurements was strong (R2 = 0.74). Bias was 42 g and 95% limits of agreement ranged from − 736 to 819 g. Agreement was particularly high in smaller lesions. Conclusions The AI-based method is suitable for the detection of lung lesions and automatic calculation of TLG in small- to medium-sized tumours. In a clinical setting, it will have an added value due to its capability to sort out negative examinations resulting in prioritised and focused care on patients with potentially malignant lesions.

We integrated clinical vignettes into routine programmatic supervision to assess community health worker knowledge of integrated community case management in rural Liberia. Results included higher rates of correct diagnosis and lifesaving treatment for uncomplicated disease than for more severe cases, with accurate recognition of danger signs posing a challenge., Key Findings Administration of vignettes in a community setting in rural Liberia was feasible and effective for measuring community health worker (CHW) knowledge of case management for the 3 major causes of child mortality addressed by integrated management of childhood illness. Correct diagnosis and lifesaving treatment for uncomplicated malaria were high, but correct diagnosis and treatment rates for complicated conditions including pneumonia with a danger sign were low. Although use of existing digital and paper-based clinical decision support job aids was inconsistent, CHWs who used them had statistically significant higher rates of correct diagnosis and treatment. Key Implications Improving the quality of CHW-delivered care is an important component of achieving universal health coverage, but gaps exist in how to measure knowledge and quality of delivery in remote settings. Clinical vignettes offer a potential approach for program implementers and policy makers to measure CHW knowledge, as a first step to incorporating assessments of the quality of CHW-delivered care into national CHW programs., Introduction: Community health workers (CHWs) can provide lifesaving treatment for children in remote areas, but high-quality care is essential for effective delivery. Measuring the quality of community-based care in remote areas is logistically challenging. Clinical vignettes have been validated in facility settings as a proxy for competency. We assessed feasibility and effectiveness of clinical vignettes to measure CHW knowledge of integrated community case management (iCCM) in Liberia's national CHW program. Methods: We developed 3 vignettes to measure knowledge of iCCM illnesses (malaria, diarrhea, and pneumonia) in 4 main areas: assessment, diagnosis, treatment, and caregiver instructions. Trained nurse supervisors administered the vignettes to CHWs in 3 counties in rural Liberia as part of routine program supervision between January and May 2019, collected data on CHW knowledge using a standardized checklist tool, and provided feedback and coaching to CHWs in real time after vignette administration. Proportions of vignettes correctly managed, including illness classification, treatment, and referral where necessary, were calculated. We assessed feasibility, defined as the ability of clinical supervisors to administer the vignettes integrated into their routine activities once per year for each CHW, and effectiveness, defined as the ability of the vignettes to measure the primary outcomes of CHW knowledge of diagnosis and treatment including referrals. Results: We were able to integrate this assessment into routine supervision, facilitate real-time coaching, and collect data on iCCM knowledge among 155 CHWs through delivery of 465 vignettes. Diagnosis including severity was correct in 65%–82% of vignettes. CHWs correctly identified danger signs in 44%–50% of vignettes, correctly proposed referral to the facility in 63% of vignettes including danger signs, and chose correct lifesaving treatment in 23%–65% of vignettes. Both diagnosis and lifesaving treatment rates were highest for malaria and lowest for severe pneumonia. Conclusion: Administration of vignettes to assess knowledge of correct iCCM case management was feasible and effective in producing results in this setting. Proportions of correct diagnosis and lifesaving treatment varied, with high proportions for uncomplicated disease, but lower for more severe cases, with accurate recognition of danger signs posing a challenge. Future work includes validation of vignettes for use with CHWs through direct observation, strengthening supportive supervision, and program interventions to address identified knowledge gaps.

Background and Purpose— There is great interest in how endovascular clot retrieval hubs provide services to a population. We applied a computational method to objectively generate service boundaries for such endovascular clot retrieval hubs, defined by traveling time to hub. Methods— Stroke incidence data merged with population census to estimate numbers of stroke in metropolitan Melbourne, Australia. Traveling time from randomly generated addresses to 4 endovascular clot retrieval–capable hubs (Royal Melbourne Hospital [RMH], Monash Medical Center [MMC], Alfred Hospital [ALF], and Austin Hospital [AUS]) estimated using Google Map application program interface. Boundary maps generated based on traveling time at various times of day for combinations of hubs. Results— In a 2-hub model, catchment was best distributed when RMH was paired with MMC (model 1a, RMH 1765 km 2 and MMC 1164 km 2 ) or with AUS (model 1c, RMH 1244 km 2 and AUS 1685 km 2 ), with no statistical difference between models ( P =0.20). Catchment was poorly distributed when RMH was paired with ALF (model 1b, RMH 2252 km 2 and ALF 676 km 2 ), significantly different from both models 1a and 1c (both P P Conclusions— We provide proof of concept for a novel computational method to objectively designate service boundaries for endovascular clot retrieval hubs.

To assess changes in the use of essential maternal and child health services in Konobo, Liberia, after implementation of an enhanced community health worker (CHW) programme.The Liberian Ministry of Health partnered with Last Mile Health, a nongovernmental organization, to implement a pilot CHW programme with enhanced recruitment, training, supervision and compensation. To assess changes in maternal and child health-care use, we conducted repeated cross-sectional cluster surveys before (2012) and after (2015) programme implementation.Between 2012 and 2015, 54 CHWs, seven peer supervisors and three clinical supervisors were trained to serve a population of 12 127 people in 44 communities. The regression-adjusted percentage of children receiving care from formal care providers increased by 60.1 (95% confidence interval, CI: 51.6 to 68.7) percentage points for diarrhoea, by 30.6 (95% CI: 20.5 to 40.7) for fever and by 51.2 (95% CI: 37.9 to 64.5) for acute respiratory infection. Facility-based delivery increased by 28.2 points (95% CI: 20.3 to 36.1). Facility-based delivery and formal sector care for acute respiratory infection and diarrhoea increased more in agricultural than gold-mining communities. Receipt of one-or-more antenatal care sessions at a health facility and postnatal care within 24 hours of delivery did not change significantly.We identified significant increases in uptake of child and maternal health-care services from formal providers during the pilot CHW programme in remote rural Liberia. Clinic-based services, such as postnatal care, and services in specific settings, such as mining areas, require additional interventions to achieve optimal outcomes.Évaluer les changements dans le recours aux services essentiels de santé maternelle et infantile à Konobo, au Libéria, après la mise en œuvre d'un programme de perfectionnement des agents de santé communautaires.Le ministère de la Santé libérien s'est associé avec Last Mile Health, une organisation non gouvernementale, afin de mettre en œuvre un programme pilote destiné à améliorer le recrutement, la formation, l'encadrement et la rémunération des agents de santé communautaires. Pour évaluer les changements au niveau des soins de santé maternelle et infantile, nous avons réalisé plusieurs sondages transversaux par grappes avant (2012) et après (2015) la mise en œuvre du programme.Entre 2012 et 2015, 54 agents de santé communautaires, sept collègues superviseurs et trois superviseurs cliniques ont été formés pour prendre en charge une population de 12 127 personnes dans 44 communautés. Le pourcentage corrigé par régression d'enfants recevant des soins de la part de prestataires de soins officiels a augmenté de 60,1 (intervalle de confiance (IC) de 95%: 51,6 à 68,7) points de pourcentage pour la diarrhée, de 30,6 (IC 95%: 20,5 à 40,7) pour la fièvre et de 51,2 (IC 95%: 37,9 à 64,5) pour les infections aiguës des voies respiratoires. Les accouchements en maternité ont augmenté de 28,2 points (IC 95%: 20,3 à 36,1). Les accouchements en maternité et la prise en charge dans le secteur formel des infections aiguës des voies respiratoires et des cas de diarrhée ont davantage augmenté dans les communautés agricoles que dans celles vivant de l'extraction de l'or. Nous n’avons pas observé de changements significatifs dans le fait de bénéficier d'une ou plusieurs séances de soins prénataux dans une structure de soins ou de soins post-partum dans les 24 heures suivant l'accouchement.Nous avons observé une augmentation significative de la prestation de services de santé maternelle et infantile par des prestataires officiels lors du programme pilote destiné aux agents de santé communautaires dans les régions rurales isolées du Libéria. Des interventions supplémentaires sont nécessaires pour obtenir des résultats optimaux vis-à-vis de la prestation de services cliniques, comme les soins post-partum, et de services dans des zones spécifiques, comme les régions minières.Evaluar los cambios en el uso de servicios de salud materna e infantil básicos en Konobo, Liberia, tras la implementación de un programa mejorado de trabajadores comunitarios de salud (CHW, por sus siglas en inglés).El Ministerio de Salud de Liberia se asoció conEntre 2012 y 2015, 54 CHW, 7 supervisores homólogos y 3 supervisores clínicos recibieron formación para trabajar para una población de 12 127 personas en 44 comunidades. El porcentaje ajustado a la regresión de niños que recibieron atención de profesionales sanitarios formales aumentó un 60,1% (intervalo de confianza (IC) del 95%: 51,6 a 68,7) para la diarrea, un 30,6% (IC del 95%: 20,5 a 40,7) para la fiebre y un 51,2% (IC del 95%: 37,9 a 64,5) para la infección respiratoria aguda. El suministro en centros aumentó un 28,2% (IC del 95%: 20,3 a 36,1). El suministro en centros y la atención del sector formal para la infección respiratoria aguda y la diarrea aumentaron más en comunidades agrícolas que en las de minas de oro. La recepción de una o más sesiones de atención prenatal en un centro sanitario y de atención posparto a las 24 horas del parto no experimentó cambios importantes.Se identificaron aumentos significativos en la aceptación de los servicios de atención sanitaria materna e infantil de profesionales formales durante la versión piloto del programa de CHW en la Liberia rural remota. Los servicios clínicos, como la atención posparto y los servicios en lugares concretos, como zonas mineras, requieren intervenciones adicionales para lograr unos resultados óptimos.تقييم التغييرات التي طرأت على الاستعانة بالخدمات الضرورية لصحة الأمهات والأطفال في كونوبو بليبيريا بعد تنفيذ برنامج محسّن للأخصائيين الصحيين للمجتمع المحلي.دخلت وزارة الصحة الليبيرية في إطار من الشراكة مع منظمة "لاست مايل هيلث" الصحية غير الحكومية لتنفيذ برنامج تجريبي للأخصائيين الصحيين للمجتمع المحلي مع تطوير عمليات التعيين والتدريب والإشراف وتقديم الأجور. ولكي يتم تقييم التغييرات في مجال الاستعانة بالرعاية الصحية للأمهات والأطفال، فقد أجريت مجموعة من الاستبيانات المجمعة القطاعية المتكررة قبل تنفيذ البرنامج (في عام 2012) وبعد تنفيذه (في عام 2015).في الفترة ما بين عاميّ 2012 و2015 تم تدريب 54 من الأخصائيين الصحيين للمجتمع المحلي، وسبعة مشرفين من النظراء، وثلاثة مشرفين سريريين لتقديم الخدمة لشريحة سكانية يبلغ قوامها 12،127 نسمة في 44 مجتمعًا محليًا. وقد زادت النسبة المئوية المعدّلة وفقًا لنموذج الانحدار الإحصائي للأطفال الذين يتلقون الرعاية من مقدمي الرعاية الرسميين بمقدار 60.1 (بمستوى ثقة تبلغ نسبته 95‏%: 51.6 إلى 68.7) نقطة مئوية بالنسبة للإسهال، وبمقدار 30.6 (بمستوى ثقة تبلغ نسبته ‏95%: 20.5 إلى 40.7) نقطة مئوية للحمى، وبمقدار 51.2 (بمستوى ثقة تبلغ نسبته ‏95%: 37.9 إلى 64.5) للعدوى التنفسية الحادة. كما تزايد إجراء عمليات الولادة في المرافق الصحية بمقدار 28.2 نقطة (بمستوى ثقة تبلغ نسبته 95‏%: 20.3 إلى 36.1). وقد تحققت زيادة أكبر في نسبة عمليات الولادة في المرافق الصحية والرعاية المقدمة من جانب الجهات الرسمية لحالات العدوى الحادة في الجهاز التنفسي والإسهال في المجتمعات المحلية الزراعية بالمقارنة مع المجتمعات المحلية القائمة على تعدين الذهب. ولم تطرأ زيادة ملموسة على تلقي جلسات الرعاية لمرحلة ما قبل الولادة بمعدل جلسة واحدة أو أكثر في المرافق الصحية وخدمات الرعاية بعد الولادة خلال فترة 24 ساعة من الولادة.لقد حددنا زيادات ملموسة في حجم تلقي خدمات الرعاية الصحية للأمهات والأطفال من الجهات الرسمية خلال فترة البرنامج التجريبي للأخصائيين الصحيين للمجتمع المحلي في المناطق الريفية النائية في ليبيريا. وتحتاج الخدمات المعتمدة على العيادات – مثل الرعاية في مرحلة ما بعد الولادة - والخدمات المقدمة في بيئات محددة، مثل مناطق التعدين إلى تدخلات إضافية لتحقيق أفضل النتائج.旨在评估实施加强的社区卫生工作者 (CHW) 计划以后，利比里亚科诺博地区基本妇幼卫生服务使用情况的变化。.利比里亚卫生部联手最后一里医疗 (Last Mile Health)，一家非政府组织，实施在招募、培训、监督和报酬方面均有所加强的社区卫生工作者 (CHW) 试点计划。 为了评估妇幼保健使用的变化，我们在该计划实施之前 (2012) 和之后 (2015) 分别开展了重复性横断面群体调查。.2012 至 2015 年间，54 名社区卫生工作者、七名同伴监管员和三名临床监管员接受了培训，以服务 44 个社区内的 12 127 名居民。 从正规护理提供者处接受护理的腹泻儿童的回归调整百分比提高了 60.1【95% 置信区间 (CI)： 51.6 至 68.7】个百分点，发热儿童百分比提高了 30.6（95% CI： 20.5 至 40.7），急性呼吸道感染儿童的百分比提高了 51.2 （95% CI： 37.9 至 64.5）。 入院分娩提高了 28.2 个百分点（95% CI： 20.3 至 36.1）。 与采金地区相比，农业地区入院分娩和前往正规科室治疗急性呼吸道感染和腹泻的情况增加得更多。 在医疗机构接受一项或多项产前护理课程和产后 24 小时内护理的情况没有显著变化。.我们发现利比里亚偏远农村地区在社区卫生工作者 (CHW) 计划试点期间从正规医疗机构接受妇幼保健服务的情况显著增加。 腹泻护理等临床服务和采矿地区等特定环境下的服务，需要额外的干预才能达到最理想的效果。.Оценить изменения в использовании основных услуг в сфере охраны здоровья матерей и детей в округе Конобо, Либерия, после внедрения усовершенствованной программы для местных медицинских работников (ММР).Министерство здравоохранения Либерии вступило в партнерские отношения с неправительственной организацией Last Mile Health для внедрения пробной программы ММР, предполагающей усовершенствования в наборе кадров, обучении, надзоре и оплате труда. Чтобы оценить изменения в использовании услуг в сфере охраны здоровья матерей и детей, авторы провели несколько межсекторальных обследований с применением гнездовой выборки до (2012 год) и после (2015 год) внедрения программы.В период между 2012 и 2015 годами было подготовлено 54 ММР, семь инспекторов из партнерских организаций и три инспектора из клиник для обслуживания 12 127 человек в 44 сообществах. Скорректированная, рассчитанная с помощью модели регрессии доля детей, которые получили медицинскую помощь от официальных работников здравоохранения, увеличилась на 60,1 (95% доверительный интервал, ДИ: 51,6–68,7) процентного пункта в случае с диареей, на 30,6 (95% ДИ: 20,5–40,7) при лихорадке и на 51,2 (95% ДИ: 37,9–64,5) при острых респираторных инфекциях. Доля родов, принятых в учреждениях, увеличилась на 28,2 пункта (95% ДИ: 20,3–36,1). Доля родов, принятых в учреждениях, и помощи, оказанной со стороны официального сектора при острых респираторных заболеваниях и диарее, увеличилась больше в сельскохозяйственных общинах, чем в золотодобывающих. Изменения в доле получивших дородовую медицинскую помощь в рамках одного или нескольких сеансов в медицинском учреждении и послеродовой уход в течение 24 часов после родов не были статистически значимы.Авторы выявили существенное увеличение в использовании услуг в сфере охраны здоровья матерей и детей, оказываемых официальными медицинскими работниками, в ходе реализации пробной программы ММР в удаленных сельских регионах Либерии. Клинические услуги, такие как послеродовой уход, и обслуживание в специфических условиях, таких как районы разработки полезных ископаемых, требуют осуществления дополнительных вмешательств для достижения оптимального результата.

Background The Deauville score (DS) is a clinical tool, based on the comparison between lesion and reference organ uptake of 18F-fluorodeoxyglucose (FDG), used to stratify patients with lymphoma into categories reflecting their disease status. With a plethora of positron emission tomography with computed tomography (PET-CT) hard- and software algorithms, standard uptake value (SUV) in lesions and reference organs may differ which affects DS classification and therefore medical treatment. The EANM Research Ltd. (EARL) harmonization program from the European Association of Nuclear Medicine (EANM) partly mitigates this issue, but local preferences are common in clinical practice. We have investigated the discordance in DS calculated from patients with lymphoma referred for 18F-FDG PET-CT reconstructed with three different algorithms: the newly introduced block-sequential regularization expectation-maximization algorithm commercially sold as Q. Clear (QC, GE Healthcare, Milwaukee, WI, USA), compliant with the newly proposed updated EARL recommendations, and two settings compliant with the current EARL recommendations (EARLlower and EARLupper, representing the lower and upper limit of the EARL recommendations). Methods Fifty-two patients with non-Hodgkin and Hodgkin lymphoma were included (18 females and 34 males). Segmentation of mediastinal blood pool and liver were semi-automatically performed, whereas segmentation of lesions was done manually. From these segmentations, SUVmax and SUVpeak were obtained and DS calculated. Results There was a significant difference in DS between the QC algorithm and EARLlower/EARLupper (p

Contains fulltext : 208975.pdf (Publisher’s version ) (Open Access) BACKGROUND: Cerebral microbleeds are a neuroimaging biomarker of stroke risk. A crucial clinical question is whether cerebral microbleeds indicate patients with recent ischaemic stroke or transient ischaemic attack in whom the rate of future intracranial haemorrhage is likely to exceed that of recurrent ischaemic stroke when treated with antithrombotic drugs. We therefore aimed to establish whether a large burden of cerebral microbleeds or particular anatomical patterns of cerebral microbleeds can identify ischaemic stroke or transient ischaemic attack patients at higher absolute risk of intracranial haemorrhage than ischaemic stroke. METHODS: We did a pooled analysis of individual patient data from cohort studies in adults with recent ischaemic stroke or transient ischaemic attack. Cohorts were eligible for inclusion if they prospectively recruited adult participants with ischaemic stroke or transient ischaemic attack; included at least 50 participants; collected data on stroke events over at least 3 months follow-up; used an appropriate MRI sequence that is sensitive to magnetic susceptibility; and documented the number and anatomical distribution of cerebral microbleeds reliably using consensus criteria and validated scales. Our prespecified primary outcomes were a composite of any symptomatic intracranial haemorrhage or ischaemic stroke, symptomatic intracranial haemorrhage, and symptomatic ischaemic stroke. We registered this study with the PROSPERO international prospective register of systematic reviews, number CRD42016036602. FINDINGS: Between Jan 1, 1996, and Dec 1, 2018, we identified 344 studies. After exclusions for ineligibility or declined requests for inclusion, 20 322 patients from 38 cohorts (over 35 225 patient-years of follow-up; median 1.34 years [IQR 0.19-2.44]) were included in our analyses. The adjusted hazard ratio [aHR] comparing patients with cerebral microbleeds to those without was 1.35 (95% CI 1.20-1.50) for the composite outcome of intracranial haemorrhage and ischaemic stroke; 2.45 (1.82-3.29) for intracranial haemorrhage and 1.23 (1.08-1.40) for ischaemic stroke. The aHR increased with increasing cerebral microbleed burden for intracranial haemorrhage but this effect was less marked for ischaemic stroke (for five or more cerebral microbleeds, aHR 4.55 [95% CI 3.08-6.72] for intracranial haemorrhage vs 1.47 [1.19-1.80] for ischaemic stroke; for ten or more cerebral microbleeds, aHR 5.52 [3.36-9.05] vs 1.43 [1.07-1.91]; and for >/=20 cerebral microbleeds, aHR 8.61 [4.69-15.81] vs 1.86 [1.23-1.82]). However, irrespective of cerebral microbleed anatomical distribution or burden, the rate of ischaemic stroke exceeded that of intracranial haemorrhage (for ten or more cerebral microbleeds, 64 ischaemic strokes [95% CI 48-84] per 1000 patient-years vs 27 intracranial haemorrhages [17-41] per 1000 patient-years; and for >/=20 cerebral microbleeds, 73 ischaemic strokes [46-108] per 1000 patient-years vs 39 intracranial haemorrhages [21-67] per 1000 patient-years). INTERPRETATION: In patients with recent ischaemic stroke or transient ischaemic attack, cerebral microbleeds are associated with a greater relative hazard (aHR) for subsequent intracranial haemorrhage than for ischaemic stroke, but the absolute risk of ischaemic stroke is higher than that of intracranial haemorrhage, regardless of cerebral microbleed presence, antomical distribution, or burden. FUNDING: British Heart Foundation and UK Stroke Association.

Transient Ischaemic Attack (TIA) if untreated carries a high risk of early stroke and is associated with poorer long-term survival [1]. There is emerging evidence of a reduction in stroke risk following TIA. Time critical investigations and management, as well as service organisation remain key to achieving good outcomes. Patients are diagnosed with TIA if they have transient, sudden-onset focal neurological symptoms which usually completely and rapidly resolve by presentation. The tissue based definition of TIA guides the fact that patients with residual symptoms should be considered as potentially having a stroke, with urgent evaluation regarding eligibility for thrombolysis and/or endovascular clot retrieval (ECR). Essential investigations for all patients with TIA should include early brain imaging, ECG, and carotid imaging in patients with anterior circulation symptoms. After brain imaging, exclusion of high risk indicators and immediate administration of an antiplatelet agent, subsequent attention to other mechanistic factors can be managed safely as part of a structured clinical pathway supervised by stroke specialists. This is in line with the recently revised Stroke Foundation Clinical Guidelines for Stroke Management (2017).

Stroke thrombolysis with alteplase is currently recommended 0-4·5 h after stroke onset. We aimed to determine whether perfusion imaging can identify patients with salvageable brain tissue with symptoms 4·5 h or more from stroke onset or with symptoms on waking who might benefit from thrombolysis.In this systematic review and meta-analysis of individual patient data, we searched PubMed for randomised trials published in English between Jan 1, 2006, and March 1, 2019. We also reviewed the reference list of a previous systematic review of thrombolysis and searched ClinicalTrials.gov for interventional studies of ischaemic stroke. Studies of alteplase versus placebo in patients (aged ≥18 years) with ischaemic stroke treated more than 4·5 h after onset, or with wake-up stroke, who were imaged with perfusion-diffusion MRI or CT perfusion were eligible for inclusion. The primary outcome was excellent functional outcome (modified Rankin Scale [mRS] score 0-1) at 3 months, adjusted for baseline age and clinical severity. Safety outcomes were death and symptomatic intracerebral haemorrhage. We calculated odds ratios, adjusted for baseline age and National Institutes of Health Stroke Scale score, using mixed-effects logistic regression models. This study is registered with PROSPERO, number CRD42019128036.We identified three trials that met eligibility criteria: EXTEND, ECASS4-EXTEND, and EPITHET. Of the 414 patients included in the three trials, 213 (51%) were assigned to receive alteplase and 201 (49%) were assigned to receive placebo. Overall, 211 patients in the alteplase group and 199 patients in the placebo group had mRS assessment data at 3 months and thus were included in the analysis of the primary outcome. 76 (36%) of 211 patients in the alteplase group and 58 (29%) of 199 patients in the placebo group had achieved excellent functional outcome at 3 months (adjusted odds ratio [OR] 1·86, 95% CI 1·15-2·99, p=0·011). Symptomatic intracerebral haemorrhage was more common in the alteplase group than the placebo group (ten [5%] of 213 patients vs one [1%] of 201 patients in the placebo group; adjusted OR 9·7, 95% CI 1·23-76·55, p=0·031). 29 (14%) of 213 patients in the alteplase group and 18 (9%) of 201 patients in the placebo group died (adjusted OR 1·55, 0·81-2·96, p=0·66).Patients with ischaemic stroke 4·5-9 h from stroke onset or wake-up stroke with salvageable brain tissue who were treated with alteplase achieved better functional outcomes than did patients given placebo. The rate of symptomatic intracerebral haemorrhage was higher with alteplase, but this increase did not negate the overall net benefit of thrombolysis.None.

Background and Purpose: Post-stroke pneumonia is a feared complication of stroke as it is associated with greater mortality and disability than in those without pneumonia. Patients are often kept “Nil By Mouth” (NBM) after stroke until after receiving a screen for dysphagia and declared safe to resume oral intake. We aimed to assess the proportional contribution of stroke severity and dysphagia screen to pneumonia by borrowing idea from coalition game theory on fair distribution of marginal profit (Shapley value). Method: Retrospective study of admissions to the stroke unit at Monash Medical Center in 2015. Seventy-five percent of data were partitioned into training set and the remainder (25%) into validation set. Variables associated with pneumonia (p < 0.1) were entered into Shapley value regression and conditional decision tree analysis. Results: In 2015, there were 797 admissions and 617 patients with ischemic and hemorrhagic stroke (age 69.9 ± 16.2, male = 55.0%, National Institute of Health Stroke Scale/NIHSS 8.1 ± 7.9). The frequency of pneumonia was 6.6% (41/617). In univariable analyses NIHSS, time to dysphagia screen, Charlson comorbidity index (CCI), and age were significantly associated with pneumonia but not weekend admission. Shapley value regression showed that the largest contributor to the model was stroke severity (72.8%) followed by CCI (16.2%), dysphagia screen (3.8%), and age (7.2%). Decision tree analysis yielded an NIHSS threshold of 14 for classifying people with (27% of 75 patients) and without pneumonia (2.5% of 308 patients). The area under the ROC curve for training data was 0.83 (95% CI 0.75–0.91) with no detectable difference between the training and test data (p = 0.4). Results were similar when dysphagia was exchanged for the variable dysphagia screen. Conclusion: Stroke severity status, and not dysphagia or dysphagia screening contributed to the decision tree model of post stroke pneumonia. We cannot exclude the chance that using dysphagia screen in this cohort had minimized the impact of dysphagia on development of pneumonia.

Ependymomas are neuroectodermal tumours arising from the ependymal lining of the ventricles and central canal of the spinal cord. Intradural extramedullary (IDEM) ependymomas which are multifocal, and/or anaplastic (WHO grade III) at presentation are exceedingly rare. We present the second case of multifocal anaplastic IDEM ependymoma in the literature. A 47-year old female presented with left gluteal and thigh pain radiating to the groin associated with paraesthesiae. She had a normal neurological examination. Magnetic resonance imaging of the lumbar spine and subsequent magnetic resonance imaging (MRI) of the remaining neuroaxis demonstrated >10 lesions throughout cervical, thoracic and lumbosacral levels. There were no intracranial lesions. The patient initially underwent surgery for removal of three symptomatic lesions at S2. She recovered well. One year later she had further surgery for three progressing lesions at T5. Four of six lesions were WHO grade III. Two smaller nodules at T5 were WHO grade II. The patient had mild sensory disturbance over the right side of the trunk which resolved posteoperatively. There were no long-term sequelae. The patient subsequently underwent full craniospinal irradiation using proton beam therapy. Due to their rarity, there are no guidelines for the management of multifocal IDEM ependymoma. The only previously published case of multifocal anaplastic IDEM ependymoma by Schuurmans et al. involved surgical resection and 20 cycles of whole-spine radiotherapy. Schuurmans patient unfortunately died two years post-diagnosis with progressive cranial metastases and post-radiation myelopathy. In our case, all remaining lesions are stable and she is neurologically intact at 48-month follow up.

Background Prognostication following hypoxic ischemic encephalopathy (brain injury) is important for clinical management. The aim of this exploratory study is to use a decision tree model to find clinical and MRI associates of severe disability and death in this condition. We evaluate clinical model and then the added value of MRI data. Method The inclusion criteria were as follows: age ≥17 years, cardio-respiratory arrest, and coma on admission (2003–2011). Decision tree analysis was used to find clinical [Glasgow Coma Score (GCS), features about cardiac arrest, therapeutic hypothermia, age, and sex] and MRI (infarct volume) associates of severe disability and death. We used the area under the ROC (auROC) to determine accuracy of model. There were 41 (63.7% males) patients having MRI imaging with the average age 51.5 ± 18.9 years old. The decision trees showed that infarct volume and age were important factors for discrimination between mild to moderate disability and severe disability and death at day 0 and day 2. The auROC for this model was 0.94 (95% CI 0.82–1.00). At day 7, GCS value was the only predictor; the auROC was 0.96 (95% CI 0.86–1.00). Conclusion Our findings provide proof of concept for further exploration of the role of MR imaging and decision tree analysis in the early prognostication of hypoxic ischemic brain injury.

Background and purpose Cerebral microbleeds (CMBs), cortical superficial siderosis, white matter lesions (WML), and cerebral atrophy may signify greater bleeding risk particularly in patients in whom anticoagulation is to be considered. We investigated their prevalence and associations with stroke type in patients with stroke and atrial fibrillation (AF). Materials and Methods Cross-sectional sample, Monash Medical Centre (Melbourne, Australia) between 2010 and 2013, with brain MRI. MRI abnormalities were rated using standardized methods. Logistic regression was used to study associations adjusting for age and sex. Results There were 170 patients, mean age 78 years (SD 9.8), 154 (90.6%) with ischemic stroke. Prevalence of MRI markers were any microbleed 49%, multiple (≥2) microbleeds 30%, confluent WMLs 18.8%, siderosis 8.9%, severe cerebral atrophy 37.7%. Combinations of the severe manifestations of these markers were much less prevalent (2.9–12.4%). Compared with ischemic stroke, those with hemorrhagic stroke were more likely to have ≥10 microbleeds (OR 5.50 95% CI 1.46–20.77, p = 0.012) and siderosis (OR 6.24, 95% CI 1.74–22.40, p = 0.005). Siderosis was associated with multiple microbleeds (OR 8.14, 95% CI 2.38–27.86, p = 0.001). Patients admitted with hemorrhagic stroke and multiple microbleeds were more frequently anticoagulated prior to stroke (6/7, 85.7%) than in those with single (1/2, 50%) or no microbleeds (4/7, 57%). Conclusion Multiple CMBs, severe WML, and severe cerebral atrophy were common individually in hospitalized patients with stroke and AF, but less so in combination. A higher burden of CMBs may be associated with intracerebral hemorrhage in stroke patients with AF.

Background The Ebola virus disease (EVD) epidemic has threatened access to basic health services through facility closures, resource diversion, and decreased demand due to community fear and distrust. While modeling studies have attempted to estimate the impact of these disruptions, no studies have yet utilized population-based survey data. Methods and Findings We conducted a two-stage, cluster-sample household survey in Rivercess County, Liberia, in March–April 2015, which included a maternal and reproductive health module. We constructed a retrospective cohort of births beginning 4 y before the first day of survey administration (beginning March 24, 2011). We then fit logistic regression models to estimate associations between our primary outcome, facility-based delivery (FBD), and time period, defined as the pre-EVD period (March 24, 2011–June 14, 2014) or EVD period (June 15, 2014–April 13, 2015). We fit both univariable and multivariable models, adjusted for known predictors of facility delivery, accounting for clustering using linearized standard errors. To strengthen causal inference, we also conducted stratified analyses to assess changes in FBD by whether respondents believed that health facility attendance was an EVD risk factor. A total of 1,298 women from 941 households completed the survey. Median age at the time of survey was 29 y, and over 80% had a primary education or less. There were 686 births reported in the pre-EVD period and 212 in the EVD period. The unadjusted odds ratio of facility-based delivery in the EVD period was 0.66 (95% confidence interval [CI] 0.48–0.90, p-value = 0.010). Adjustment for potential confounders did not change the observed association, either in the principal model (adjusted odds ratio [AOR] = 0.70, 95%CI 0.50–0.98, p = 0.037) or a fully adjusted model (AOR = 0.69, 95%CI 0.50–0.97, p = 0.033). The association was robust in sensitivity analyses. The reduction in FBD during the EVD period was observed among those reporting a belief that health facilities are or may be a source of Ebola transmission (AOR = 0.59, 95%CI 0.36–0.97, p = 0.038), but not those without such a belief (AOR = 0.90, 95%CI 0.59–1.37, p = 0.612). Limitations include the possibility of FBD secular trends coincident with the EVD period, recall errors, and social desirability bias. Conclusions We detected a 30% decreased odds of FBD after the start of EVD in a rural Liberian county with relatively few cases. Because health facilities never closed in Rivercess County, this estimate may under-approximate the effect seen in the most heavily affected areas. These are the first population-based survey data to show collateral disruptions to facility-based delivery caused by the West African EVD epidemic, and they reinforce the need to consider the full spectrum of implications caused by public health emergencies., John Kraemer and colleagues estimate changes in facility-based delivery during the Ebola virus disease epidemic in rural Liberia using cross-sectional data from a population-based household survey., Author Summary Why was this study done? The 2014–2015 West African Ebola virus disease (EVD) epidemic killed approximately 11,300 people directly, but its effects are magnified by collateral health consequences. Mathematical models and facility-based data provide evidence of substantial health service interruptions, but little population-based survey data has been published from the three principally affected countries. Maternal health services, which are dependent on functioning health systems, are likely to be particularly susceptible to external shocks, such as the EVD epidemic. What did the researchers do and find? We used a cluster-sample survey to produce a representative sample of births in Rivercess County, Liberia, a part of the country with relatively limited Ebola transmission. Controlling for potential confounders, we compared the odds of facility-based delivery among 686 births in the period before the EVD epidemic with 212 births during the epidemic. We identified a 30% reduction in the odds of facility-based delivery during the EVD epidemic. The odds of facility-based delivery were 41% lower among women who reported a belief that Ebola was or may be transmitted in health facilities, but not significantly lower among women who reported believing that Ebola was not transmitted in health facilities. What do these findings mean? This study provides further evidence that the 2014–2015 West African EVD epidemic caused serious collateral harm to health services. This study also underscores the need to maintain focus on long-term health system reconstruction after the EVD epidemic.

Background Lacunar infarct has been characterized as small subcortical infarct. It is postulated to occur from “in situ microatheroma or lipohyalinosis” in small vessel or lacunar mechanism. Based on this idea, such infarcts by lacunar mechanism should not be associated with large area of perfusion deficits that extend beyond the subcortical region to the cortical region. By contrast, selected small subcortical infarcts, as defined by MR imaging in the subacute and chronic stage, may initially have large perfusion deficit or related large vessel occlusions. These infarcts with “lacunar” phenotype may also be caused by disease in the parent vessel and may have very different stroke mechanism from small vessel disease. Our aim is to describe differences in imaging characteristics between patients with small subcortical infarction with “lacunar phenotype” from those with lacunar mechanism. Materials and methods Patients undergoing acute CT perfusion/angiography (CTP/CTA) within 6 h of symptom onset and follow-up magnetic resonance imaging (MRI) for ischemic stroke were included (2009–2013). Lacunar infarct was defined as a single subcortical infarct ≤20 mm on follow-up MRI. Presence of perfusion deficits, vessel occlusion, and infarct dimensions was compared between lacunar infarcts and other topographical infarct types. Results Overall, 182 patients (mean age 66.4 ± 15.3 years, 66% males) were included. Lacunar infarct occurred in 31 (17%) patients. Of these, 12 (39%) patients had a perfusion deficit compared with those with any cortical infarction (120/142, 67%), and the smallest lacunar infarct with a perfusion deficit had a diameter of

Background and Purpose— Although cerebral white matter lesions (WMLs), silent infarcts (SIs), and microbleeds (MBs) are individually associated with poorer gait and balance, it is unknown if they interact. We studied the interactions of WML volume with SI and MB on gait and postural stability. Methods— Participants in a population-based study aged 60 to 86 years underwent brain MRI, computerized gait measurement, and a physiological profile assessment of postural stability. Segmentation procedures and standard rating methods were used to measure WML, SI, and MB. Linear regression was used to test interactions between lesions on gait and postural stability, adjusting for age, sex, and total intracranial volume. Results— There were 395 participants (mean age, 72 years; SD, 7.0). SIs were predominantly located in subcortical frontal white matter and in deep gray structures, and MBs were largely lobar. Participants with SI or MB had higher WML volumes than those without ( P P =0.05, respectively). The presence of SI ( P for interaction=0.01) or MB ( P for interaction P for interaction=0.02), but not MB, magnified the adverse association of WML volume with postural stability. Conclusions— Subclinical cerebrovascular lesions are adversely associated with gait and postural stability in older people in a cumulative fashion.

Differentiating hemorrhagic infarct from parenchymal intracerebral hemorrhage can be difficult. The immediate and long-term management of the two conditions are different and hence the importance of accurate diagnosis. Using a series of intracerebral hemorrhage cases presented to our stroke unit, we aim to highlight the clues that may be helpful in distinguishing the two entities. The main clue to the presence of hemorrhagic infarct on computed tomography scan is the topographic distribution of the stroke. Additional imaging modalities such as computed tomography angiogram, perfusion, and magnetic resonance imaging may provide additional information in differentiating hemorrhagic infarct from primary hemorrhages.

The mismatch between perfusion weighted images (PWI) and diffusion weighted images (DWI) using MR is increasingly being applied in patient selection for therapeutic trials. Two approaches to the calculation of the mismatch volume exist--the commonly used volumetric and the more precise co-registration method, the latter of which considers lesion topography. That there are differences in the mismatch volume analysed by each method and that these are time dependent was hypothesised.Patients within 48 h of ischaemic stroke onset had baseline MR PWI/DWI mismatch and T2 outcome volumes at 3 months. Volumetric mismatch volume was defined as PWI minus DWI lesion. Co-registration mismatch volume was defined as the PWI defect lesion not overlapped by the co-registered DWI lesion.72 patients of median age 74.0 years were studied. Median baseline MR was at 5.9 h (IQR 3.0, 20.4 h) after stroke onset. Consistent underestimation of the mismatch volume occurred using the volumetric method (volumetric median 9.3 ml, IQR 0, 63 ml; co-registration median 20.1 ml, IQR 3.2, 69.8 ml; p0.0001). This difference increased with time from stroke onset (p = 0.006).Volumetric analysis consistently underestimates the PWI/DWI mismatch volume compared with the more precise co-registration method. This effect increases with time.

Background and Purpose In acute ischemic stroke perfusion/diffusion-weighted image, mismatch using magnetic resonance imaging approximates the ischemic penumbra. For early time windows, mismatch salvage improves clinical outcomes, but uncertainty exists at later time epochs. We hypothesized that (a) mismatch may exist up to 48 h; (b) the proportion of mismatch salvage is time independent; and (c) when salvaged, it improves clinical outcomes. Methods Magnetic resonance imaging was performed within 48 h of ischemic stroke. Perfusion-weighted image was defined by relative Tmax two-second delay. Perfusion/diffusion-weighted image mismatch was the perfusion-weighted image not overlapped by the diffusion-weighted image when coregistered. Infarct volume and disability (modified Rankin Score) were assessed at three-months. Mismatch salvage was the region not overlapped by final infarction. Favorable outcome was defined as modified Rankin Score 0–1. Results Sixty-six patients were studied [mean age 69·9 years (standard deviation 13·1), initial median National Institute of Health Stroke Scale 9·0 (interquartile range 6·0, 18·3)]. There was no relationship between time of stroke onset and the proportion of mismatch salvaged ( P = 0·73). Age (adjusted odds ratio = 0·92, 95% confidence interval 0·86–0·98, P = 0·01), initial National Institute of Health Stroke Scale (adjusted odds ratio = 0·80, 95% confidence interval 0·70–0·92, P < 0·01), mismatch volume (adjusted odds ratio = 0·98, 95% confidence interval 0·968–0·1, P = 0·05), and percentage of mismatch salvage (adjusted odds ratio = 1·04, 95% confidence interval 0·99–1·07, P = 0·05) were independently associated with favorable outcome. Conclusion Using coregistered perfusion/diffusion-weighted image criteria, mismatch persists up to 48 h post stroke. For the whole group, the proportion of mismatch salvage remains independent of time and, although the effect is small, its salvage is independently associated with improved clinical outcomes at three-months. Larger sample sizes are needed to determine the time limit for mismatch salvage.

Background: It has been described that lacunar infarct is characterized by its smallish size (15-20 mm) in the axial plane. However, the size of the basal ganglia artery responsible for this type of infarct is uncertain. Detection of small arterial occlusion is not possible with current angiography, hindering correlation of arterial occlusion with subcortical infarct size. Recently, investigators have published microangiographic templates of arteries supplying the basal ganglia. These templates display first-order (proximal) to third-order (distal) branching of these arteries and can help with estimating the likely site of arterial disease in subcortical infarcts. We correlated the dimensions of subcortical infarcts with the order of arterial branching described in a microangiographic template. Such data may provide further clues about the type of arteries associated with subcortical infarcts and assist in refining the concept of lacunar infarction. Method: Patients with subcortical infarcts on MR imaging (MRI) admitted to our institution between 2009 and 2011 were included in the study. Infarcts were manually segmented and registered to a standard brain template. These segmented infarcts were scaled and overlapped with published microangiographic templates, and used by 6 raters who independently estimated the branching order of arterial disease that might result in these infarcts. We used regression analysis to relate these ratings to infarct dimensions. Results: Among 777 patients, there were 33 (58% male) patients with subcortical infarcts. The mean age was 63.1 ± 15.1 years. Infarct dimensions for the groups were as follows: group 1 (first-order branch): height 37.6 ± 7.4 mm, horizontal width 21.2 ± 11.6 mm, anterior-posterior length 36.8 ± 20.1 mm; group 2 (second-order branch): height 25.2 ± 7.9 mm, horizontal width 16.6 ± 22.8 mm, anterior-posterior length 16.1 ± 8.0 mm; group 3 (third-order branch): height 11.6 ± 5.7 mm, axial width 5.3 ± 3.1 mm, anterior-posterior length 5.5 ± 3.8 mm. Increasing vessel branching order (from large to small vessels) was linearly and negatively associated with infarct height (β = -16.7 mm per change in branching order disease, 95% CI -20.3, -13.1 mm, p < 0.01) and anterior-posterior length (β = -16.8 mm per change in branching order disease, 95% CI -23.2, -10.5 mm, p < 0.01). Discussion: Based on MRI infarct dimensions and a microangiographic template, it may be possible to estimate the branching order of the artery involved in subcortical infarcts. Further, our small data set suggests that reliance on an axial dimension of 15-20 mm may not be the best approach to classifying lacunar infarct. This finding needs to be confirmed in a larger data set.

The regions at risk of ischemia following cardio-respiratory arrest have not been systematically analysed. This knowledge may be of use in determining the mechanism of ischemic injury at vulnerable sites. The aim of this study is to evaluate the use of principal component analysis to analyse the covariance patterns of hypoxic ischemic injury. The inclusion criteria were: age ≥ 17 years, cardio-respiratory arrest and coma on admission (2003-2011). Regions of ischemic injury were manually segmented on fluid attenuated inversion recovery (FLAIR) and diffusion weighted (DWI) sequences and linearly registered into common stereotaxic coordinate space. Topography of ischemic injury was assessed using principal component analysis (covariance data) and compared qualitatively against current method of topography analysis, the probabilistic method (frequency data). For the probabilistic data, subgroup analyses were performed using t-statistics while for the covariance data, subgroup analyses were performed by calculating the angle between the principle components. To account for bias due to a higher frequency of coma survivors in the studied group, we performed sensitivity analysis by sequentially removing coma survivors such that the final data set contained higher rate of death. Quantitative analysis between these methods could not be performed as they have different units of measurement. Forty one patients were included in this series (mean age ± SD=51.5 ± 18.9 years). In our probabilistic map, the highest frequency of ischemic injury on the DWI and FLAIR sequences was putamen (0.250), caudate (0.225), temporal lobes (0.175), occipital (0.150) and hippocampus (0.125). The first 6 principal components contained 77.7% of the variance of the data. The first component showed covariance between the deep grey matter nuclei and posterior cortical structures (contains 50.2% of the variance of the data). There was similarity in the findings of the subgroup analyses by the downtime whether it was assessed by t-statistics for probabilistic data or angle between the principal components for the covariance data. The sensitivity analysis showed that the pattern of ischemic injury did not change when the analysis was restricted to patients who died. In conclusion, PCA method has many advantages over probabilistic method. In the context of this dataset, PCA showed covariance between deep grey matter nuclei and the posterior cortical structures whereas the probabilistic map provided complementary information on the frequency of occurrence at these locations.

P2-106 NO ASSOCIATION BETWEEN PRESENCE OF CAROTID DISEASE AND 11C-PIB-PET IN ACUTE STROKE PATIENTS Ramesh Sahathevan, Brodtmann Amy, Victor Villemagne, Paul Yates, Leonid Churilov, John Ly, Thomas Linden, Christopher Rowe, Geoffrey Donnan, Florey Neuroscience Institutes/Universiti Kebangssan Malaysia, Melbourne, Australia; Florey Neuroscience Institutes/Melbourne University, Melbourne, Australia; Austin Health/Mental Health Research Institute, Melbourne, Australia; Austin Health/Melbourne University, Melbourne, Australia; Florey Neuroscience Institutes/Monash University, Melbourne, Australia; Gothernburg University, Gothenburg, Australia; Austin Health, Heidelberg, Melbourne, Australia.

Background and Purpose— In ischemic stroke, MR perfusion-weighted imaging (PWI) and diffusion-weighted imaging (DWI) mismatch represents tissue at risk for infarction. Infarct growth should only take place in the presence of mismatch, although there have been reports of this occurring. We hypothesized that this observation may be attributable to the presence of undetected “hidden mismatch,” which may become obvious when coregistration techniques are used. Methods— MR PWI/DWI was performed within 48 hours of stroke onset and a final T2-weighted image at ≈3 months. Volumetric-subtraction mismatch volume was defined as PWI minus DWI volume and infarct growth was defined as T2 minus DWI volume. Coregistration mismatch volume was PWI not overlapped by DWI. Mismatch salvage was the proportion of coregistered mismatch tissue that had not progressed to infarction. Results— Thirty-four patients were studied with MR at a median of 4.9 hours (interquartile range, 2.9–21.1 hours). With the volumetric-subtraction technique, 5 patients (14.7%; 95% CI, 0.05%–0.31%) had infarct growth exceeding mismatch volume, 11 patients (32.0%) had no mismatch and, among these, 3 (27.3%) had infarct growth (median volume, 2.2 mL; interquartile range, 1.0–6.5 mL). All patients had mismatch volume identified by coregistration method that was greater than infarct growth volume. The proportion of this volume salvaged was 77.7% (interquartile range, 63.0%–98.9%). Conclusions— The illogical finding of infarct growth volume being greater than the presence of mismatch volume can be explained by the presence of “hidden mismatch,” which may be detected by coregistration methods.

Objective To correlate motor deficit with involvement of corticofugal fibres in patients with subcortical stroke. The descending motor corticofugal fibres originate from the primary motor cortex (M1), dorsal and ventral premotor area (PMdv) and supplementary motor area (SMA). Design Retrospective study. Setting Single tertiary teaching hospital. Participants 57 patients (57% men) with subcortical infarcts on MRI (2009–2011) were included. The mean age was 64.3±14.4 years. Interventions None. Primary and secondary outcome measures National Institute of Health Stroke Scale subscores for arm and leg motor deficit at 90 days. Results An area under the receiver operating characteristics curve (AUC) for the volume of overlap with infarct (and M1/PMdv/SMA fibres) and motor outcome was calculated. The AUC for the association with arm motor deficit from M1 fibres involvement was 0.80 (95% CI 0.66 to 0.94), PMdv was 0.76 (95% CI 0.61 to 0.91) and SMA was 0.73 (95% CI 0.58 to 0.88). The AUC for leg motor deficit from M1 fibres involvement was 0.69 (95% CI 0.52 to 0.85), PMdv was 0.67 (95% CI 0.50 to 0.85), SMA was 0.66 (95% CI 0.48 to 0.84). Conclusions Following subcortical stroke, the correlations between involvement of the corticofugal fibres for upper and lower limbs motor deficit were variable. A poor motor outcome was not universal following subcortical stroke.

Attention to the quality of life (QOL) among long-term of breast cancer is long overdue. Modest improvements in overall survival have led to a greater emphasis on how women are living with the disease. The purpose of this paper is to report the results of a descriptive study that evaluated the quality of life of 294 breast cancer survivors, and to review the continuum of positive and negative QOL outcomes in this population. Members of the National Coalition for Cancer Survivorship (NCCS) were surveyed and received two QOL instruments: the Quality of Life — Cancer Survivors Tool (QOL-CS) and the Functional Assessment of Cancer Therapy (FACT-G), and a demographic data tool. The main research variables were the subscales (Physical, Psychological, Social, and Spiritual Well-being) and individual items of the QOL-CS and the FACT-G. Results indicated that: a) fatigue, aches and pains, and sleep problems were persistent after treatment ended; b) psychological distress from cancer diagnosis and treatment, and fear of recurrent, metastatic, and recurrent disease were problematic over time; c) family distress, sexuality, and family burden issues were of greatest social concern; and d) uncertainty over the future plagued breast cancer survivors long-term. Breast cancer survivors also reported good outcomes in hopefulness, having a life purpose, and having a positive change after the treatment. Conclusions: breast cancer survivors experienced long-term changes after completion of treatment which affected overall quality of life. However, many positive benefits were also gained which helped to balance the worse outcomes.

Background Changes in maximum standardised uptake values (SUVmax) between serial PET/CT studies are used to determine disease progression or regression in oncologic patients. To measure these changes manually can be time consuming in a clinical routine. A semi-automatic method for calculation of SUVmax in serial PET/CT studies was developed and compared to a conventional manual method. The semi-automatic method first aligns the serial PET/CT studies based on the CT images. Thereafter, the reader selects an abnormal lesion in one of the PET studies. After this manual step, the program automatically detects the corresponding lesion in the other PET study, segments the two lesions and calculates the SUVmax in both studies as well as the difference between the SUVmax values. The results of the semi-automatic analysis were compared to that of a manual SUVmax analysis using a Philips PET/CT workstation. Three readers did the SUVmax readings in both methods. Sixteen patients with lung cancer or lymphoma who had undergone two PET/CT studies were included. There were a total of 26 lesions. Results Linear regression analysis of changes in SUVmax show that intercepts and slopes are close to the line of identity for all readers (reader 1: intercept = 1.02, R2 = 0.96; reader 2: intercept = 0.97, R2 = 0.98; reader 3: intercept = 0.99, R2 = 0.98). Manual and semi-automatic method agreed in all cases whether SUVmax had increased or decreased between the serial studies. The average time to measure SUVmax changes in two serial PET/CT examinations was four to five times longer for the manual method compared to the semi-automatic method for all readers (reader 1: 53.7 vs. 10.5 s; reader 2: 27.3 vs. 6.9 s; reader 3: 47.5 vs. 9.5 s; p < 0.001 for all). Conclusions Good agreement was shown in assessment of SUVmax changes between manual and semi-automatic method. The semi-automatic analysis was four to five times faster to perform than the manual analysis. These findings show the feasibility of using semi-automatic methods for calculation of SUVmax in clinical routine and encourage further development of programs using this type of methods.