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A dual left anterior descending (LAD) coronary artery is a rare, and benign congenital anomaly. In this anomaly, there is the presence of two LADs in the anterior inter ventricular sulcus (AIVS). One of the LADs is a short one that ends high in the AIVS. The other longer one enters the distal AIVS and feeds the apex. To date, 9 types of dual LAD variants, and one novel type X has been reported. Herein, we report a case of type X dual LAD with a literature review.

Congenital heart defects (CHD) are cardiovascular malformations that generally occur due to aberrant development of a normal structure in the fetus, or failure of such a structure to progress beyond an early stage of embryonic or fetal development. Malformations are due to complex multi-factorial genetic and environmental causes. Congenital heart defects, in a definition proposed by Mitchell et al, is a gross structural abnormality of the heart or intrathoracic great vessels that are actually or potentially of functional significance. A comprehensive approach to every aspect of CHD, covering from embryology, fetal malformations, pathology, clinical approach, investigations, interventions to the surgery is very essential to reduce the morbidity and mortality in children with CHD. Key words: Congenital malformation, Great vessels, Fetus, ASD,VSD,TOF.

Objective: Abnormal right ventricular function plays an important role in development of clinical symptoms and overall prognosis of patients with mitral stenosis. Hemodynamic and radionuclide studies have demonstrated long-term improvement in RV function after PTMC. However, exact quantification by conventional echocardiographic technique is difficult owing to complex 2D anatomy. This study evaluates the immediate and short term follow up impact of successful percutaneous transvenous mitral valve commissurotomy (PTMC) on RV function in patients with mitral stenosis using 2D Echo and Doppler tissue imaging. Methods: 219 patients (mean age 26 + 6yrs) with rheumatic MS, all in sinus rhythm were studied before and 24-48 hrs after PTMC. Parameters of global and longitudinal RV function were assessed by conventional 2D ECHO and Doppler tissue imaging. Results: Immediately following PTMC, mitral valve area increased from baseline of 0.71 ± 0.15 cm 2 to 1.84 ± 0.17 cm 2 (P 0.0001), RV outflow tract fractional shortening (RVOT–FS) increased from 33.94 ± 7.55% to 37.33 ± 7.67% ( Conclusion: Long term evaluation of RV function and benefits using invasive and radionuclide methods post PTMC has shown incongruous results in improvement of right ventricular (RV) function immediately after PTMC. In this study, immediately after successful PTMC significant improvement in parameters of infundibular and global RV function as assessed by RVOT fractional shortening , Tei index and tissue Doppler velocities was observed. Key words: PTMC, RV function, ECHO indices-2D and DTI, procedural outcome-immediate and short term.

A 42-year-old woman was admitted with history of recurrent syncope of more than 10 to 15 episodes per day for more than 3 months that worsened over 1 month. She was diagnosed to have aortoarteritis type I 3 years before when angiography showed total occlusion of bilateral subclavian ([Figures 1A

Background and Purpose— Within different brain regions, we determine the comparative value of multiphase computed tomographic angiography (mCTA) and computed tomographic perfusion (CTP) in predicting follow-up infarction. Methods— Patients with M1-middle cerebral artery occlusions were prospectively included in this multicenter study. Regional analysis was performed for each patient within Alberta Stroke Program Early CT Score regions M2 to M6. Regional pial vessel filling was assessed on mCTA in 3 ways: (1) Washout of contrast within pial vessels; (2) Extent of maximal pial vessel enhancement compared with contralateral hemisphere; (3) Delay in maximal pial vessel enhancement compared with contralateral hemisphere. Cerebral blood flow, cerebral blood volume, and Tmax data were extracted within these Alberta Stroke Program Early CT Score regions. Twenty-four- to 36-hour magnetic resonance imaging/CT was assessed for infarct in each Alberta Stroke Program Early CT Score region (defined as >20% infarction within that region). Mixed effects logistic regression models were used to compare mCTA and CTP parameters when predicting brain infarction. Area under the receiver operating characteristics was used to assess discriminative value of statistical models. Results— Seventy-seven patients were included. mCTA parameter washout and CTP parameter Tmax were significantly associated with follow-up infarction in all models ( P P >0.05). Mean Tmax and cerebral blood volume values were significantly different between each washout score ( P P P Conclusions— Similar to CTP, multiphase CTA can be used to predict tissue fate regionally in acute ischemic stroke patients.

Objective Aim of the study was to evaluate clinical, angiographic profile and percutaneous endovascular management of Takayasu's arteritis. Background Takayasu's arteritis is a chronic inflammatory vasculitis affecting the aorta and its major branches. Although it is more prevalent in Asia, the distribution of the disease is worldwide with different vascular involvement patterns and clinical manifestations. Methods In this prospective study a total of 50 consecutive patients who were reported as having Takayasu's arteritis between January 2010 and April 2016 were evaluated. Detailed clinical presentation and angiograms of all patients were analysed. Results 50 patients were analysed during study period. Among 50 patients, 43(86%) were female and 7 (14%) were male. Average age of presentation was 26.92 years. Most common clinical presentation was claudication (74%) followed by, musculoskeletal symptoms (48%), fatigue (46%), weight loss (22%), headache (22%), visual disturbances (16%), syncope (10%), dyspnoea (20%). Most common features were absent/diminished pulses (80%), difference in blood pressure (80%), followed by bruit (70%)hypertension (64%), cerebrovascular accident (8%),heart failure (8%) and aortic regurgitation (4%). According to the new angiographic classification, angiographic type I (40%) was encountered most frequently, followed by type III (30%), type V (16%), type IIb (8%), type IIa (2%), and type IV is (4%). Angioplasty was the main stay of treatment in 66% of the patients, remaining 34% of them were treated medically either with corticosteroids or methotrexate. Conclusion Takayasu's arteritis is a rare disease, affects mainly women, manifestations range from asymptomatic disease, found as a result of impalpable pulses or bruits, to catastrophic neurological impairment. Takayasu's arteritis is the common cause of renovascular hypertension. Angiography remains the gold standard for diagnosis. Angiographic evaluation and percutaneous transluminal angioplasty with stenting is useful in selected cases.

Introduction: The use of CT Perfusion (CTP) in acute ischemic stroke (AIS) to determine patients with large ischemic core is still hampered by slow processing time, among other technical/standardization issues. Multi-phase CTA (mCTA) may be quicker and more practical in this regard. We sought to determine i) the performance of mCTA and CTP to predict regional infarction and ii) which mCTA construct(s) corresponds to which CTP parameter . Methods: mCTA and CTP was performed less than 12hrs from ictus in 77 patients with MCA-M1 occlusions. Regional analysis was performed within M2-M6 ASPECTS-regions. mCTA: regional pial vessels were assessed according to three constructs: i) Delay in maximal pial vessel enhancement compared to contralateral hemisphere; ii) Washout of contrast within pial vessels; iii) Extent of maximal pial vessel enhancement compared to contralateral hemisphere (Figure 1). CTP-CBF, CBV, MTT, IRF-T0, and Tmax values were determined. 24-hour MR-DWI or NCCT was used for final infarction. Results: There was a negligible difference in the predictive accuracy of mCTA and CTP in discriminating infarction (i.e., 84.59% and 83.04%, respectively). mCTA-Extent had the largest discriminatory power, while CTP-Tmax had the largest discriminatory power. Conclusion: Herein we show that mCTA assessments, even within small brain regions can help determine tissue fate when adjusted for recanalization, and is as good as CTP. mCTA may be a more practical modality to obtain similar prognostic information for radiological and clinical outcomes in AIS, informing acute treatment and tertiary centre triaging.

Background and Purpose— Minor stroke and transient ischemic attack with an intracranial occlusion are associated with neurological deterioration and disability. Tenecteplase (TNK–tissue-type plasminogen activator) compared with alteplase is easier to administer, has a longer half-life, higher fibrin specificity, possibly a lower rate of intracranial hemorrhage, and may be an ideal thrombolytic agent in this population. Methods— TNK–Tissue-Type Plasminogen Activator Evaluation for Minor Ischemic Stroke With Proven Occlusion (TEMPO-1) was a multicenter, prospective, uncontrolled, TNK–tissue-type plasminogen activator dose-escalation, safety, and feasibility trial. Patients with a National Institutes of Health Stroke Scale ≤5 within 12 hours of symptom onset, intracranial arterial occlusion on computed tomographic angiography and absence of well-evolved infarction were eligible. Fifty patients were enrolled; 25 patients at a dose of 0.1 mg/kg, and 25 patients at 0.25 mg/kg. Primary outcome was the rate of drug-related serious adverse events. Secondary outcomes included recanalization and 90-day neurological outcome (modified Rankin Scale, 0–1). Results— Median baseline National Institutes of Health Stroke Scale was 2.5 (interquartile range, 1), and median age was 71 (interquartile range, 22) years. There were no drug-related serious adverse events in tier 1. In tier 2, there was 1 symptomatic intracranial hemorrhage (4%; 95% confidence interval, 0.01–20.0). Stroke progression occurred in 6% of cases. Overall, 66% had excellent functional outcome (modified Rankin Scale, 0–1) at 90 days. Recanalization rates were high; 0.1 mg/kg (39% complete and 17% partial), 0.25 mg/kg (52% complete and 9% partial). Complete recanalization was significantly related to excellent functional outcome (modified Rankin Scale, 0–1) at 90 days (relative risk, 1.65; 95% confidence interval, 1.09–2.5; P =0.026). Conclusions— Administration of TNK–tissue-type plasminogen activator in minor stroke with intracranial occlusion is both feasible and safe. A larger randomized controlled trial is needed to prove that this treatment is efficacious. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT01654445.

Introduction: Multi-phase CTA (mCTA) is a new imaging tool that generates time resolved images of contrast filling-in and washout within pial vessels in ischemic brain regions. In this study, we seek to demonstrate criterion and predictive validity of this imaging tool regionally by comparing vascular status as assessed using mCTA with CT perfusion estimates and with final tissue fate. Methods: Data is from PRove-IT, an ongoing multi-national prospective study that seeks to understand the utility of multi-modal imaging in the triage of acute ischemic stroke patients. Only patients with M1-MCA occlusions were included for the analysis. “Delay” in maximal pial vessel enhancement, “Extent” of maximal pial vessel enhancement and degree of “Washout” of contrast within these pial vessels was each graded on a 3-point scale in each of the 5 ASPECTS regions (M2-6)(Fig 1). CBF, CBV, MTT, T Max and T0 values were calculated within these same ASPECTS regions on CTP. Reperfusion status was assessed regionally using the Kim’s template. Final tissue fate per region was determined on 24 hr MR/CT. Results: We included 45 patients (225 ASPECTS regions) in the study. Specific parameters on mCTA correlated with specific perfusion estimates on CTP [Delay and T0 time (Kruskal-Wallis p=0.001), Washout and MTT (p15ml/100gm/min using a combined “Washout+Extent” grade on mCTA. In the early reperfusers, this combined “Washout+Extent” grade was related significantly with tissue fate regionally (Fisher’s p=0.04). Conclusion: Regional vascular status on mCTA provides similar information to CTP estimates and is capable of predicting final tissue fate regionally.

BACKGROUND: Recent STIR guidelines stress the importance of speed and the need to balance the benefits of multi-modal imaging against potential treatment delay. It is essential that studies report on relevant imaging time intervals (ITIs) including image acquisition and interpretation times. We analyzed frequency of various ITIs reported. METHODS: The search strategy was conducted by combining the themes of acute ischemic stroke, perfusion imaging, and CT/MRI. Two independent reviewers screened at all levels and disagreements were settled through consensus. The inclusion criteria was CT/MR perfusion within 24 hours of stroke symptom onset and thresholds reporting for core, penumbra, and/or normal/not at risk tissue. We collected data on relevant a priori specified ITIs from each study (Table 1) and report these as medians (of either mean or median interval time in each individual study). RESULTS: The search resulted in 9184 abstracts from EMBASE, 7249 abstracts from MEDLINE resulting in 11919 abstracts after duplicates. Of 711 studies identified for full-text review, 94 studies reported at least one relevant time interval. Pooled estimates (medians with IQR) are reported for each ITI (Table 1). We noted lack of clarity on whether these ITIs were reporting beginning or end of image (CT or MRI) acquisition. Only 3/94 (3.4%) studies reported admission to imaging time. 54/134 (40%) studies reported image acquisition time; no studies reported on image interpretation times. CT acquisition (30 studies) ranged from 30-120 seconds with a median of 47 (41.25-58.75) seconds. MRI acquisition ranged from 46-144 seconds with a median of 69.50 (60.0-84.25) seconds. CONCLUSION: ITIs are significantly under-reported in studies that describe the use of multi-modal imaging (CT/MR perfusion). There exists significant heterogeneity in the definitions of many ITIs. Admission to end of imaging acquisition, an important marker of optimized workflow is minimally reported.

Background: CT Perfusion (CTP) may inform treatment decisions in acute ischemic stroke (AIS). We sought to determine extent of variability with CTP thresholds for infarct core and penumbra and reasons for such variability using an up-to-date systematic review. Methods: Search strategy combined the themes of AIS, perfusion imaging, and CT/MRI. Two independent reviewers screened at all levels; disagreements were settled through consensus. Inclusion criteria were CTP within 24hrs of stroke onset and reported perfusion thresholds for infarct core, penumbra, and/or normal/not at risk tissue for mixed grey/white matter. Study demographics, QUADAS assessment of quality, and mean thresholds of cerebral blood volume (CBV), cerebral blood flow (CBF), mean transit time (MTT), relative CBV (rCBV), relative CBF (rCBF), and relative MTT (rMTT) were collected. Thresholds were reported as median mean threshold (interquartile range). Results: The search resulted in a total of 11919 abstracts from EMBASE and MEDLINE. Of these, 711 studies were identified for full-text review, 134 met all eligibility criteria. 29 studies provided thresholds for CTP and were included in the review. For CBF, median mean threshold was 8.64 (7.94-13.92) ml/min/100g for core, 19.1 (17.1-31.9) ml/min/100g for penumbra and 47.4 (35.6-59.1) ml/min/100g for normal/not at risk tissue. For CBV, median mean threshold was 1.0 (0.68-1.88) ml/100g for core, 2.45 (2.0-3.0) ml/100g for penumbra, and 2.65 (2.0-3.3) ml/100g for normal/not at risk tissue. For MTT median mean threshold was 15.6 (15.3-17.7) seconds for core, 10.5 (7.1-46.2) seconds for penumbra, and 3.9 (3.65-4.15) seconds for normal/not at risk tissue. Median mean threshold for rCBF was 29% (22.5%-35.5%) for core. Sufficient TTP and Tmax data were not reported. Overall, quality was highly variable according QUADAS ranging from 20.7% to 93.1% across the 14 variables. Conclusions: Due to heterogeneity of vendor CTP algorithms, follow-up imaging to define infarct core (NCCT, DWI), unknown recanalization times/reperfusion status and differing onset to CT times, CTP thresholds for infarct core and penumbra are highly variable. As such, a single best threshold for core could not be derived from literature.

Background: MRI susceptibility-weighted imaging (SWI) provides better contrast and is typically done at higher spatial resolution than MRI T2*-weighted gradient-recalled echo (GRE), increasing the sensitivity for cerebral microbleed (CMB) detection. However, few studies have implemented SWI and GRE in the same scan session, and there is uncertainty regarding whether findings on SWI are comparable to findings on GRE. We compared the sensitivity and reliability of SWI vs. GRE sequences for detecting CMBs in a community population. Methods: Using a standardized case report form, two radiologists independently identified CMBs on SWI and GRE in 247 participants age 40 to 75 in the community-based Prospective Urban Rural (PURE) MIND substudy. MRI was performed on the same GE 3T MRI scanner using typical clinical sequence parameters. SWI and GRE were read >2 weeks apart. After the independent readings, the two raters met to determine CMB presence by consensus. Results: Mean age was 58.0±7.6 years, 65% were women, 23% had hypertension and 8.6% had diabetes. By consensus, CMBs were seen in 30 participants (12.2%) on SWI but in only 13 (5.2%) on GRE (p Conclusions: More than twice as many CMBs were detected on MRI SWI compared to GRE, with the same inter-rater reliability. SWI may be the preferred sequence for detecting CMBs, given its greater sensitivity. However, CMB distribution patterns and risk factors were similar regardless of sequence type, suggesting that the findings of studies using either sequence are comparable.

Background: In the setting of acute ischemic stroke, CT Perfusion (CTP) may change thrombolytic/endovascular treatment decisions when compared to NCCT/CTA alone. Two distinct thresholds may be useful in this regard: separation of 1) non-salvageable tissue (infarct core) from salvageable electrically silent tissue (penumbra), and 2) penumbra from benign oligemia (hypoperfused, but will survive if clot persists). Methods: CTP (120s,8cm) was performed on 180 patients within 12hrs of ischemic stroke. Two patient cohorts were analyzed: (1) recanalization (TICI 2b,3) 6s. For group (2) CBF, CBV, and Tmax values were obtained from within the final infarct region, and total ipsilateral hemisphere, excluding infarction. CBF, CBV and Tmax were used in univariate regression models. Results: For group (1)[n=11], mean time from CTP to recanalization was 60±19min. CBF parameter (thresholds for gray and white matter 7.2 and 5.2 ml•min-1•(100g)-1) had the highest sensitivity (90.9%) and specificity (81.8%) for infarction. For group (2)[n=15], the Tmax parameter (thresholds for gray and white matter 11.3s and 11.8s) had the highest sensitivity (86.6%) and specificity (80.0%) for penumbra. Conclusion: CTP thresholds derived from ultra-early reperfusers could potentially best define what is clinically dead in patients with acute ischemic stroke

Introduction: The quality of reporting of neuroimaging methods for studies of cerebral small vessel disease is unknown. We systematically reviewed studies of MRI white matter hyperintensities (WMH) of vascular origin to determine the frequency of reporting of key aspects of neuroimaging methods, and whether reporting varied by sample size, study design or journal impact factor. Methods: Three raters independently reviewed 100 consecutive papers reporting WMH severity, either as a primary outcome or covariate, to abstract 50 study characteristics based on the published STRIVE standards (Wardlaw et al Lancet Neurol 2013). Final determinations were made by consensus. An aggregate quality score (range 0-11) was created by adding one point for reporting of each of 11 key characteristics (Table). Spearman correlation or chi-square test, as appropriate, were used to test associations with quality score. Results: Papers were published between 2009 and 2013 with journal impact factors ranging from 0.56 to 15.3, with cohort (79%) and case control (21%) studies represented. Quantitative computational methods were used in 28 studies. MR field strength, MRI sequence types, type of WMH measurement method, blinding and number of raters were reported frequently, but reporting of other characteristics was inconsistent (Table). Study quality score was not correlated with journal impact factor, sample size or cohort study design. Conclusions: There is inconsistent reporting of neuroimaging methods in the small vessel disease imaging literature. Increased adherence to published reporting standards, such as the STRIVE criteria, may facilitate more objective peer review of submitted manuscripts and increase the reproducibility of published results. More work is needed to facilitate adoption of standards and checklists by authors, reviewers and editors.

Shone’s complex is a Congenital Heart Disease (CHD), consisting of multiple levels of left sided obstructive lesions including supravalvular mitral membrane (SVMM), parachute mitral valve, subaortic stenosis and coarctation of aorta. Cortriatriatum sinister is a rare congenital defect in which a membrane divides LA into two distinct chambers. These two congenital malformations are rare and their occurrence together is still rarer. We report a 1 year 3 month old male baby with h/o failure to thrive, recurrent Respiratory Tract Infection & developmental delay. Presented with rarer combination of shone’s complex and cortriatriatum sinister. Key words: Shone’s complex, Cortriatriatum sinister, Congenital Heart Disease, 2DEchocardiography, Cortriatriatum dexter

Idiopathic dilatation of the right atrium (IDRA), also known as the giant right atrial aneurysm (RAA), is a rare anomaly, usually asymptomatic and of unknown etiology. It can be associated with atrial arrhythmias, severe tricuspid regurgitation (TR), congestive heart failure, thrombus formation leading to pulmonary embolism, paradoxical embolism, and stroke. IDRA can be misdiagnosed as Ebstein’s anomaly or Uhl’s anomaly due to the hugely dilated right atrium (RA) in both the anomalies. The imaging modalities such as two-dimensional transthoracic echocardiography (2DTTE), threedimensional (3DTTE), computed tomography (CT), and cardiac magnetic resonance imaging (MRI) can be very useful in differentiating the various causes for dilated RA and thereby aiding in the management of this congenital abnormality.

Background The assessment of the IVC diameter is self explanatory for evaluation of the individuals’ volume status. Studies regarding IVC diameter estimation in normal individuals are scarce. Aim The present study aimed to define normal criteria of size and dynamics of the inferior vena cava (IVC) by M-mode echocardiography in normal individuals. Methods This was a prospective, single-center, observational study carried out at Sri Jayadeva Institute of Cardiovascular Sciences and Research between December 2011 and April 2014. A total of 4126 consecutive individuals were enrolled. Normal IVC diameter was measured both during inspiration and expiration by M-mode echocardiography in subcostal view. Results The IVC diameter varied from 0.46 to 2.26 cm in the study individuals. The IVC diameter ranged from 0.97 to 2.26 cm during expiration and from 0.46 to 1.54 cm during inspiration. A strong correlation was observed between IVC diameter and height, weight and BMI of the individuals, calculated using Pearson correlation. The correlation coefficients for expiratory and inspiratory IVC diameters as a function of BMI were 0.686 and 0.7, respectively. Conclusions Our findings corroborate the correlations between height, weight and BMI with IVC diameter. Future studies could be focused to bring about a steadfast formula for calculating IVC diameter based on demographic parameters of an individual.

The presence of tendon xanthomas is an almost certain indicator of familial hypercholesterolemia (FH). They also reflect coronary atherosclerotic burden and therefore must be treated aggressively. Tendon xanthomas also occur in two rare conditions, cerebrotendinous xanthomatosis and sitosterolemia, which are not easily confused with FH, can be easily differentiated with clinical history and biochemical tests.